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25 Cards in this Set
- Front
- Back
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three requirnments for reporting
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accurate, thorough, and timely records of care and observations of each resident are critical.
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why is careful observation important?
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helps prevent serious probloms with the residents health and reduces safty hazards. it increases your awarness of each resident's physical, emotional, and social needs.
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alert physical change
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decreased or increased functioning of v.s.
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alert physical change
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unconscious, weak, dizzy, drowsy
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alert physical change
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shaking, trembling, spasms
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alert physical change
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chest pains
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alert physical change
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cold, pale, clammy, chills
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alert physical change
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hot, burning, sweating, feverish
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alert physical change
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nausea, vomiting
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alert physical change
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diarrhea, constipation
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alert physical change
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excessive thirst, change in appetite
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alert physical change
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odor
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alert physical change
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change in skin color
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alert physical change
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ringing in ears, blurred vision, swelling, edema, rash, hives, blisters, choking, coughing, wheezing, sneezing, SOB, red irrated skin, pus, drainage, weakness
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alert in emotional change
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mood swings, loss of contol, depressed, crying, angry, disoriented, confussed, anxious, scarried, pacing, restless
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end-of-shift reports
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are made to the oncoming staff that provide good information to continue good care.
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objective reporting
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report only what you see, smell, feel, or hear.
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objective reporting
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if resident c/o symptoms that you can't observe, report exactly what they tell you.
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correct reporting e.g.
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Mrs. smith said her left ear aches, as reported to the supervisor.
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subjective reporting
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used to report what you can't see. - e.g. Mrs. smith says her ear ached, and she seems very uncomfortable, as reported to the supervisor.
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charting
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a residents medical record in writting.if not charted then legally it did not get done.
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the chart is a permenet, legal record of care that includes...
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progress notes, dr. orders, meds, Tx, flow sheets, x-rays, and lab reports.
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resident care flow sheet
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details and checklist of ADL. e.g. I/O, tray monitor, turning schedule, BM and bladder training, behavior modifications
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procedure for charting in a residents record
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p.t. name on each paper, write clearly in ink, correct errors by single line through it and signing, p completing and not a, any reports and observations, facts only, thorough but breif.
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charts are confidential
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keeping the info confidential is your responsibility- legally, ethicly, and moraly.
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