| -These are organized into sections for easy use.|
-Each page is stamped with the client's name, room and bed number, and other identifying information.
-Health team members record information on the forms for their departments.
|The record (chart) has many forms|
| *Telling a story|
*All details to be included
*Begin with date, time
-What you did and when
-Whom you reported to
-The client's response
-Any results or problems
|SOAP DAR PIE FAIR||Methods of Charting|
|Only health care team members involved in the client's care have access to confidential information||Access to the client's charter|
|Computer systems and some personal digital assistants collect, send, record, and store information||PDAs|
|The care planning process has five steps:|
|(also known as nursing process) is the method nurses use to plan and deliver nursing care||The care planning process|
|Assessment involves collecting information about the client||Assessment|
|never ends||The assessment step|
| -You make many observations as you give care and talk to the client.|
-Objective data (signs) are seen heard, felt, or smelled.
-Subjective data (symptoms) are things a client tells you about that you cannot observe through your senses
|Support workers play a key role in assessment|
| -The RN uses assessment information to make a nursing diagnosis.|
-A nursing diagnosis describes a health problem that can be treated by nursing measures.
-A client can have many nursing diagnoses.
-They deal with the total person (physical, emotional, social, and spiritual needs).
| -Planning involves setting priorities and goals.|
-The needs are arranged in order of importance.
-Goals are then set
-Nursing interventions are chosen after goals are set
|is an action or measure taken by the nursing team to help the client reach a goal||a Nursing interventions|
| -Is a written guide about the client's care|
-Has the client's nursing diagnoses and goals
-Has the measures or actions for each goal
-Is a communication tool
-Is used by nursing staff to see what care to give
-Helps ensure that the nursing team members give the same care
|The nursing care plan (care plan)|
|it is continually reviewed and revised, depending on the client's needs, condition, and progress||The care plan is not a finished document -|
| The implementation step is performing or carrying out nursing measures in the care plan.|
-Care is given during this step.
|from simple to complex||Nursing care ranges|
|Changes in nursing diagnoses result in changes in the care plan||New observations may change the nursing diagnoses.|
| -Each client's care|
-What measures and tasks need to be done
-Which nursing tasks to do
|The assignment sheet tells you about:|
| Talk to the nurse.|
Check the care plan and Kardex.
|If an assignment is unclear:|
|The Care Plan in a Community Setting|| -Case managers co-ordinate and manage client care.|
-Meetings take place in the client's home.
-Family is very important to the assessment process, because serious illness greatly affects the family roles.
|Community Planning|| -Case manager establishes priorities, sets goals, and determines available resources. |
-Plan includes services provided by family members, outside professionals, and agencies.
-Some clients choose to co-ordinate and manage their own care.
|Community Implementation and Evaluation|| -Unforeseen needs arise - support workers must be able to adapt to request and adjust the care to best meet the client's needs.|
-Evaluation is ongoing - case manager reviews care and services.
|Evaluation|| -This step involves measuring if the goals in the planning step were met.|
-Progress is evaluated.
-Assessment information is used for this step.
-Changes in nursing diagnoses, goals, and the care plan may result.
|Support workers provide valuable information||towards this evaluation, which may result in changes being made to the care plan.|
|Support Worker Role|| The nurse uses support worker observations for nursing diagnoses and planning.|
-In the implementation step, support workers perform nursing actions and measures outlined in the care plan.
-Your observations are used for the evaluation step.
|Observations||- an active process of sensing and assimilating information.|
|Developing Observation Skills|| -Use senses:|
Sight, hearing, touch, smell
-Listening to the client breathe, noticing flushed or pale skin, noticing red swollen ankles, smelling unusual odours from urine/bowel movement