A
Harry asks you to get his shirt out of the closet for him while he is brushing his teeth. You place his shirt on his bed. He walks to his bed from the bathroom and puts the shirt on. He then walks to the dining room for breakfast. You place his breakfast in front of him and he asks for a cup of coffee. You put the coffee in front of Harry, while he is buttering his toast. (4 responses)
What is Personal Hygiene: Independent, no setup help
functional mobility in room and location: Independent, no setup help
Dressing: Independent, setup help
Eating: Independent, no setup help
Jerry is going to the dining room for lunch today. Instead of using his w/c, he is walking with you while you hold onto the gait belt to assist with balance less than 25%. This is the only time he walks during your shift. (1 response)
What is functional mobility: 1 person min assistance
Judy is nonweight bearing to her LLE as a hip replacement precaution, she needs to out of bed to her w/c for dialysis. You and Jane (CNA) use the Hoyer lift.
(1 response)
What is Transfers: Total Dependence 2 person assistance
Phil just had back surgery. You remind him to walk slowly and to stand close to the handrails when in the hallway.
What is walking in corridor: Supervision, no setup help
Jim puts on his call light, you find him standing in the bathroom. He tells you that he just used the toilet and needs you help zipping and buttoning up his pants.
What is What is Toilet Use: Limited 1 person assistance
Mary can get combative with cares. You are brushing her hair and washing her face while Jane is singing a song with Mary.
What is Personal Hygiene: Total dependence 1 person assistance.
You helped Maggie at lunch by cutting up her meat and buttering her roll. She takes a few bites and then starts looking around the dining room and is no longer eating. You have to frequently tell her to take a bite.
What is Eating: Supervision w/set up help only
Harry is ready to go to the dining room. You push him in his w/c to the dining room.
Locomotion on unit: Total dependence 1 person assistance
Mary has not gotten out of bed during your whole shift. You and Jane have to turn and reposition her every 2 hours and ensure her feet are elevated. She is incontinent of B&B, you and Jane have clean her up, change her brief and change her clothes after an incontinent episode. Mary is also receiving nutrition through her feeding tube.
What is Transfers: Activity did not occur
Bed Mobility: Total 2 person assistance
Toilet Use: Total 2 person assistance
Dressing: Total 2 person assistance
Eating: Total 1 person assistance
Jack is ready to go to bed. He needs your assistance to transfer to bed and sit on the edge of the bed. You help he put his feet up on the bed. Jack then grabs onto the side rail and helps you turn and reposition him.
What is Transfers: Extensive 1 person assistance
Bed Mobility: Extensive 1 person assistance
You are working the NOC shift. You are doing rounds on Ginny, she is currently lying on her right side. You assist her with incontinent care by changing her brief and providing pericare. After you change her brief, she asks for a drink of water, you hand her the water mug and she is able to take a drink of water. Before you leave her room, you assist her to lay on her left side, Ginny is able to assist by grabbing onto the side rail to turn.
What is Toilet use: Total dependent 1 person assistance
Eating: Independent setup help only
Bed Mobility: Extensive 1 person assistance
Buddy is able to dress himself in his shirt and pants. You need help him by holding his leg and foot to put on his socks and shoes.
What is Dressing: Extensive 1 person assistance
Ralphie is able to walk all the way to the activity room for the activity. Today he became very tired after his walk, and you propel him in a wheelchair back to his room, as he requested
What is Walk in Corridor: Independent, no setup help
Locomotion on & off Unit: Extensive, 1 person assistance
Mrs. Jones usually needs staff to provide cueing and guided maneuvering to assist Mrs. Jones with eating at meals. However, for lunch today, she eats in her room and her daughter assists her with eating
What is Eating: Activity Did Not Occur
Mrs. Smith is ready for her shower. Mrs. Smith is able to transfer onto the shower chair and complete most of the bathing without assistance, but you provide oversight and you hand her a soapy wash cloth. You also help wash her hair and back.
What is Bathing: Supervision, setup help only