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The 4 elements of documentation
What is...
Factual: Subjective and objective data
Accurate and concise: Document facts and information precisely (what the nurse sees, hears, feels, smells) without any interpretations of the situation. Unnecessary words and irrelevant detail are avoided. Exact measurements establish accuracy. Only abbreviations and symbols approved by The Joint Commission and the facility are acceptable.
Complete and current: Document information that is comprehensive and timely. Never pre-chart an assessment, intervention, or evaluation. Timely documentation occurs as soon after the observation or event as possible.
Organized: Communicate information in a logical sequence.
Grinding of teeth during sleep
What is...
Bruxism
This type of charting includes a more detailed and organized method when documenting client care. Sections of the medical record are divided, and the ability to share among the interdisciplinary team can be limited.
What is...
Problem-oriented medical record (POMR)
This is a cutaneous skin stimulation to interrupt pain pathways, provide cold for inflammation and heat to increase blood flow to reduce stiffness
What is...
TENS unit (Transcutaneous Electrical Nerve Stimulation) portable device provides temporary pain relief for various conditions by interfering with pain perception, making it an effective alternative for managing pain without medication
When an incident occurs, what information is documented, and what information isn't documented?
Name 3 for each
What is...
Vital signs, any additional findings, notification of the provider, treatments or procedures the provider prescribes, and the client's response.
What is not...
Judgement, assumptions, conclusions, or blame
Sudden attacks of sleep that are often uncontrollable. It can occur at inappropriate times and increases the risk of injury. With hallucinations, sleep-wake cycles.
What is...
Narcolepsy
This type of charting centers on a client’s specific problem. When using focused charting, three areas that are required for documentation are...
What is...
DAR - data, action, and response.
Nonverbal signs of pain
What is...
Restlessness, grimacing, clenching, anxiety, tightly closing eyes, biting bottom lip
The purpose of electronic documentation
What is...
This dysfunction in the respiratory control center of the brain fails to trigger breathing during sleep, as a result of a brain injury or opioid overdose.
What is...
The CNS
This type of charting includes an intervention demonstrated by the nurse to address the client’s problem.
What is...
PIE - Problem, interventions, and evaluation
What pain is caused by somatic origin or visceral origin, due to damage to bone, joints, muscle, skin, or connective tissue?
What is...
Nociceptive pain, like an injury, sprain, or strain.
This is completed by a registered nurse in a long-term care setting and contains an evaluation of each resident's assessment, including their cognitive and physical status. These forms are maintained at the facility for state compliance.
What is...
minimum data set (MDS)
Which nursing actions promote better sleep habits.
Must name 5
This type of charting utilizes standardized forms that identify norms and enable the selective documentation of deviations from those norms.
What is...
Charting by exception
This is a medication delivery system that allows clients to self-administer safe doses of opioids. Small, frequent dosing ensures consistent plasma levels.
What is...
Patient-controlled analgesia (PCA)
To prevent inadvertent overdosing, the client is the only person who should push the PCA button
Must provide 4
What is...
Factors that Interfere with Sleep
Must provide 5
Physiologic disorders: Can require more sleep or disrupt sleep (sleep apnea, nocturia)
Current life events: Traveling more, change in work hours
Emotional stress or mental illness: Anxiety, fear, grief
Diet: Caffeine consumption, heavy meals before bedtime
Exercise: Promotes sleep if completed 3 hr before bedtime, otherwise can disrupt sleep
Fatigue: Exhausting or stressful work makes falling asleep difficult.
Sleep environment: Too light, the wrong temperature, or too noisy (children, pets, loud noise, snoring partner)
Medications: Some can induce sleep but interfere with restorative sleep. Others (bronchodilators, antihypertensives) cause insomnia.
Substance use: Nicotine and caffeine are stimulants. Caffeine and alcohol tend to cause night awakenings.
Patient stated his pain has decreased to a 3 on a scale from 0 to 10.
What is a patient RESPONSE/outcome?
This....intense, shooting, burning, or described as “pins and needles.” Also includes phantom limb pain, pain below the level of a spinal cord injury, and diabetic injuries
What is...
Neuropathic pain