natcep day 4

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  • 1. 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 STNAs role in gathering and documenting information

2. 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 3. 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 residents care to ensure consistency. 4. A member of the care team. Provides/gathers data and information that will be helpful for the assessment and care planning process. 5. Vital Signs Temperature, Pulse, Respirations Skin Care Bathing, Turning & Positioning Elimination Urine, Bowel Movements Ambulation Walking, devices to help walking Mobility Independent? Staff Assistance? 6. 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 7. Chronological record of the residents 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 persons problems, treatment and care. 8. Observing the resident Reporting changes to the nurse in charge Recording information according to facility policy. Participating in care conferences. 9. Always remember if it is not documented, it was not done. 10. 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 11. Military Time 12. 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 13. 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 14. 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 15. 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? Whats the speed limit? Are there any pedestrians on the road? 16. How many cars did you see? How many trucks? How many of the vehicles in the parking lot can you describe? 17. 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? 18. Your observations can alert you to changes in the residents condition Observations should be made continuously during resident care BE ALERT at ALL TIMES 19. SEE What might we see? FEEL What might we feel? HEAR What might we hear? SMELL What might we smell? 20. What is the residents 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? 21. 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 22. Breathing is labored (difficult) Objective Chest pain Subjective Pulse Objective Dark urine Objective Nausea Subjective Sweating Objective Breath is fruity Objective Fearful Subjective 23. Changes in the residents condition are reported to the nurse immediately. Observations are reported and recorded exactly as seen, felt, heard or smelled, or in the residents own words. 24. 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 residents behavior Describe the role of the care plan and care conference in responding to a residents behavior 25. Human Psychologist Believed that individuals are controlled by their values and the choices they make Model of human needs Hierarchy of Needs 26. Physiological Needs Survival Food Water Air Sleep Sex Physiological Needs 27. Safety Security, stability, keeping us from harm Physical Security Shelter Safe environment Physiological Needs Safety 28. Love/Belonging Need to give and receive love and affection Friendship Family Sexual intimacy Physiological Needs Safety Love/Belonging 29. Esteem Confidence Content Respect self and others respect Prestige & Power Physiological Needs Safety Love/Belonging Esteem 30. Physiological Needs Safety Love/Belonging Esteem Self Actualization Become what we are capable of becoming 31. Independence Promote by Encouraging self care Encouraging decision making Clothing Food Activities 32. 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 33. Social Interaction Promote by Encouraging contact with other residents Encouraging contact with family and friends outside the LTCF 34. Recognition as an Individual Promote by Be respectful Allow for privacy Encouraging self expression through crafts, reminiscing and recognizing past accomplishments 35. Self Actualization Promote by Respect beliefs dont impose yours Learn needs and preferences that assist Encouraging activities that promote self actualization 36. Anger Demanding Self-centered Aggressive Withdrawl Inappropriate sexual behavior 37. 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