NURSING RECORDS http://www.nursingnotes.info/
FIVE (5) STAGES OF BREASTFEEDING CARE
(American Nurses Connection (ANA) Requirements of Scientific Nursing Practice)
I. ASSESING вЂ“ is a systematic and continuous collection, organizing, affirmation, and documentation of data. GOAL: To establish a database regarding client's response to health concerns or illness and the ability to take care of health care requirements.
TYPES OF ASSESSMENT:
TYPE TIME PERFORMEDPURPOSEEXAMPLE
Initial AssessmentWithin specified period after admissionTo establish a complete data base for difficulty identification, reference and upcoming comparisonNursing entry assessment Problem-focused assessmentOngoing method integrated with nursing careTo determine status of particular problem identified in an earlier assessment To distinguish new or overlooked problemsI & O q 1 hr in ICU
Determine client's capacity to perform do it yourself care although assisting to bathe Emergency AssessmentDuring any physiologic and psychologic crisis of the clientTo determine life-threatening concerns
Rapid analysis of ABC during cardiac arrest
Assessment pertaining to suicidal inclinations and potential for violence Time-lapsed reassessmentSeveral several weeks after first assessmentTo assess client's current status to baseline info previously obtainedReassessment of customer's functional health patterns.
A. DATA COLLECTION вЂ“ is a process of gathering info about a client's health status. DATABASES вЂ“ is all info about the customer; includes medical health background, physical evaluation, doctor's history and physical examination, results of lab and diagnostic assessments, and material contributed simply by other well being personel. CUSTOMER DATA вЂ“ past history and current problems.
TYPES OF DATA:
1 . VERY SUBJECTIVE DATA вЂ“ symptoms or covert (secret) data. It really is described or perhaps verified just by the affected individual. Examples: irritation, pain, worry, sensations, thoughts, values, behaviour, perception of private status and life condition. 2 . AIM DATA вЂ“ signs or perhaps overt (obvious) data. It is detectable by observer, may be measured or perhaps tested against accepted standard. They can be noticed, heard and felt, or smelled, can be obtained by remark or physical examination. SOURCES OF DATA:
1 . PRIMARY DATA вЂ“ from the CONSUMER, it is the ideal source of data unless too ill, fresh, confused to communicate clearly. 2 . SECONDARY DATA вЂ“ are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social workers), LITERATURE (standards/norms, cultural and health practices, spiritual beliefs) DATA COLLECTION METHODS
1 ) OBSERVATION вЂ“ is a conscious, deliberate skill that is created through work and with an prepared approach. 2 . INTERVIEW вЂ“ is planned communication or possibly a conversation which has a purpose. TWO APPROACHES:
a. DIRECTIVE INTERVIEW. The doctor establishes the idea and handles the interview. The client responds to queries but may limited opportunity to ask questions or discuss problems b. NONDIRECTIVE INTERVIEW вЂ“ rapport-building interview. The nurse allows the customer to control the idea, subject matter, and pacing. RAPPORT- is the understanding b/w 2 or more people.
TYPES OF INTERVIEW:
a. CLOSED ISSUE вЂ“ (directive interview) restrictive and solved by YES/NO, questions begin by WHEN, WHEREVER, WHO, WHAT, DO or perhaps IS. b. OPEN-ENDED CONCERNS вЂ“ (indirective interview) ask clients to learn, explore, sophisticated, clarify, or perhaps illustrate all their thoughts and feelings. It could begin with WHAT/HOW. c. NATURAL QUESTION вЂ“ (open ended and indirective) is a question a client can response without path or pressure from the health professional ( regarding feelings and point of views) g. LEADING CONCERNS вЂ“ (closed and directive) directs the client's solution. It gives your customer less opportunity to decide whether or not the answer is valid or certainly not. (Ex. You aren't stressed regarding the surgery tomorrow, not necessarily you? ) PLANNING AND SETTING OF INTERVIEW
a. Time. secure and unhurried