Download - Natcep day 4
NATCEP Day FourResident Comprehensive
Assessment, Care Plan and Conference
OB
JEC
TIV
ES
State the purpose of a resident comprehensive assessment
State the purpose of a resident care plan
State the purpose of the resident care conference
Identify the role of the STNA in the care planning conference
Describe the STNA’s role in gathering and documenting information
CA
RE P
LA
N &
CA
RE
CO
NFER
EN
CE
Identifies specific therapeutic actions for resident based on their individualized need
STNA should attend care conferences at periodic intervals to gain insight into caring for residents with emotional needs
PU
RP
OS
E O
F C
AR
E P
LA
N
Resident care problems and strengths to be addressed by the health care team are identified and ways to help the resident are identified.
Resident care plans are communicated to all 3 shifts and to all staff involved in the resident’s care to ensure consistency.
RO
LE O
F T
HE N
UR
SE
AID
E IN
TH
E C
AR
E
PLA
NN
ING
PR
OC
ESS
A member of the care team.
Provides/gathers data and information that will be helpful for the assessment and care planning process.
NU
RS
E A
IDE R
OLE
IN G
ATH
ER
ING
&
DO
CU
MEN
TIN
G
INFO
RM
ATIO
N
Vital Signs› Temperature, Pulse,
Respirations Skin Care
› Bathing, Turning & Positioning
Elimination› Urine, Bowel Movements
Ambulation› Walking, devices to help
walking Mobility
› Independent?› Staff Assistance?
NATCEP Day FourMedical Record
OB
JEC
TIV
ES
Identify the purpose of a medical record
Identify ways the NA can contribute to the medical record
Identify common medical abbreviations
Identify the proper methods of documentation
PU
RP
OS
E O
F A
M
ED
ICA
L R
EC
OR
D
Chronological record of the resident’s condition and care.
Legal record of medical and nursing care.
Way for the health care team to communicate information about the person.
Can be used as court evidence of a person’s problems, treatment and care.
MED
ICA
L R
EC
OR
D:
STN
A C
ON
TR
IBU
TIO
N
Observing the resident Reporting changes to
the nurse in charge Recording information
according to facility policy.
Participating in care conferences.
CR
ITIC
AL N
OTE
Always remember – if it is not documented, it was not done.
GEN
ER
AL R
ULES
: CH
AR
TIN
G
Use ink Legible & neat Agency-approved
abbreviations Correct spelling,
punctuation & grammar No erasing or white out Agency policy for error
correction Sign with first initial,
last name, and title
GEN
ER
AL R
ULES
: CH
AR
TIN
G
Military Time
GEN
ER
AL R
ULES
: CH
AR
TIN
G
Never skip lines No spaces between
entry and signature Fill in empty space with
a line Record what you did
and/or saw Chronological order Use direct quotes from
resident with quotation marks
Record safety measures Correct chart
CO
MM
ON
DO
CU
MEN
TS
TH
AT N
UR
SE A
IDES
C
OM
PLETE
I & O Sheets Meal Records Restorative Records Vital Sign Sheets &
Graphic Records ADL Records Bowel & Bladder
Program Records Examples in Chapter 6
beginning on page 66
NATCEP Day FourObservational Skills
HO
W O
BS
ER
VA
NT A
RE
YO
U?
Do your friends tell you that you notice EVERTHING – or maybe NOTHING?
Observation is critical in your role as a nursing assistant
Key objectives:› Discuss the importance of
observation› Describe various observation
techniques› Identify observations to be
made during resident care› Demonstrate how to report
and record observations
LET’S
FIN
D O
UT. . . .
WH
AT D
ID Y
OU
SEE?
Are there cars parked on the sides of the road?
What color is the pickup truck driving in the road?
Any minivans around? What does the blue sign
say? What’s the speed limit? Are there any
pedestrians on the road?
WA
NT T
O T
RY
AG
AIN
?
WH
AT D
ID Y
OU
SEE?
How many cars did you see?
How many trucks? How many of the
vehicles in the parking lot can you describe?
LA
ST O
NE. . . . .
WH
AT D
ID Y
OU
SEE?
How many vehicles where in the intersection?
Across the street, are there any vehicles parked on the side?
Can you describe at least one of the vehicles driving through the intersection?
Are there any potential witnesses?› If so, what was the witness
doing?› If so, where was he or she?
What was the speed limit? Was there anyone parked in
the first parking spot?
WH
Y IS
OB
SER
VATIO
N
IMP
OR
TA
NT?
Your observations can alert you to changes in the resident’s condition
Observations should be made continuously during resident care
BE ALERT at ALL TIMES
WAY
S T
O O
BS
ER
VE
SEE› What might we see?
FEEL› What might we feel?
HEAR› What might we hear?
SMELL› What might we smell?
OB
SER
VA
TIO
NS
OF N
OTE
What is the resident’s general appearance?
Is the resident alert, confused, drowsy?
What is their activity level? What is the color of his/her
skin, mouth, fingernails? What is the condition of
his/her breathing? How does the resident
manage eating, drinking, elimination?
Has there been a change in his/her sleeping habits?
What is his/her mood or behavior?
TY
PES
OF D
ATA
Objective: Signs› Observed through the 5
senses: seen, felt, heard, smelled or tasted
Subjective: Symptoms› Things the resident tells
you that you cannot observe through the senses
WH
AT T
YP
E O
F D
ATA
?
Breathing is labored (difficult)› Objective
Chest pain› Subjective
Pulse › Objective
Dark urine› Objective
Nausea› Subjective
Sweating› Objective
Breath is “fruity”› Objective
Fearful› Subjective
REP
OR
TIN
G &
R
EC
OR
DIN
G
Changes in the resident’s condition are reported to the nurse immediately.
Observations are reported and recorded exactly as seen, felt, heard or smelled, or in the resident’s own words.
NATCEP Day FourMeeting the Basic Emotional
Needs of Residents
OB
JEC
TIV
ES
Identify basic emotional needs of the residents in a LTCF
Identify actions the STNA can take to meet the emotional needs of the resident
Recognize common behaviors displayed when emotional needs are not met
Describe therapeutic interventions the STNA may use in response to a resident’s behavior
Describe the role of the care plan and care conference in responding to a resident’s behavior
MA
SLO
W
Human Psychologist Believed that
individuals are controlled by their values and the choices they make
Model of human needs› Hierarchy of Needs
HIE
RA
RC
HY
OF N
EED
S
Physiological Needs› Survival
Food Water Air Sleep Sex
Physiological Needs
HIE
RA
RC
HY
OF N
EED
S
Safety› Security, stability,
keeping us from harm Physical Security Shelter Safe environment
Physiological Needs
Safety
HIE
RA
RC
HY
OF N
EED
S
Love/Belonging› Need to give and receive
love and affection Friendship Family Sexual intimacy
Physiological Needs
Safety
Love/Belonging
HIE
RA
RC
HY
OF N
EED
S
Esteem Confidence Content Respect self and others’
respect Prestige & Power
Physiological Needs
Safety
Love/Belonging
Esteem
HIE
RA
RC
HY
OF N
EED
S
Physiological Needs
Safety
Love/Belonging
Esteem
Self ActualizationBecome what we are capable of becoming
BA
SIC
EM
OTIO
NA
L N
EED
S
Independence Promote by
› Encouraging self care› Encouraging decision
making Clothing Food Activities
BA
SIC
EM
OTIO
NA
L N
EED
S
Supportive Environment
Promote by› Physical Environment
Proper medical and dental care
Safe, comfortable clothing Rooms and halls clutter
free Protection from others
(and self, if needed)› Emotional Environment
Treat with respect, acceptance and patience
Supportive of family
BA
SIC
EM
OTIO
NA
L N
EED
S
Social Interaction Promote by
› Encouraging contact with other residents
› Encouraging contact with family and friends outside the LTCF
BA
SIC
EM
OTIO
NA
L N
EED
S
Recognition as an Individual
Promote by› Be respectful › Allow for privacy› Encouraging self
expression through crafts, reminiscing and recognizing past accomplishments
BA
SIC
EM
OTIO
NA
L N
EED
S
Self Actualization Promote by
› Respect beliefs – don’t impose yours
› Learn needs and preferences that assist
› Encouraging activities that promote self actualization
CO
MM
ON
BEH
AV
IOR
S
WH
EN
NEED
S A
RE N
OT
MET
Anger Demanding Self-centered Aggressive Withdrawl Inappropriate sexual
behavior
HO
W D
O Y
OU
RES
PO
ND
TO
BEH
AV
IOR
S?
Acknowledge frustration or frightening situations
Treat with dignity and respect Answer questions clearly and
thoroughly Keep them informed Do not keep them waiting Explain reasons for long waits Stay calm and professional Do not argue Listen – use silence Protect yourself from violent
behaviors Report inappropriate behavior
to the nurse