Documentation in action by Springhouse

By Springhouse

Designed for fast on-the-job reference, Documentation in Action bargains complete, authoritative, practice-oriented, up to the moment instructions for documenting each scenario in each nursing perform surroundings and significant nursing specialties. Need-to-know details is gifted in bulleted lists, charts, move sheets, sidebars, and packing containers, with icons and illustrative filled-in samples.

Coverage contains documentation for care of sufferers with quite a few illnesses, problems, emergencies, advanced techniques, and problems concerning sufferers, households, and different future health care execs. feedback are given for keeping off criminal pitfalls related to cell orders, drugs reactions, sufferers who refuse care, and lots more and plenty extra. a piece addresses automatic documentation, HIPAA confidentiality ideas, use of PDAs, nursing informatics, and digital techniques that would quickly be universal.

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Foot elevated on 2 pillows. Heel and elbow protectors applied. Skin lotion applied. Incontinent care given hourly. No other skin breakdown noted. Buttocks reddened but epidermis intact. Rachel Moreau, RN Ⅲ Use flow sheets that have defined cues to make your documentation easi- er. However, even if you use a flow sheet, write a note in the medical record if and when you notify a physician about changes in the wound or surrounding tissue. Ⅲ Watch for and document the development of risk factors for pressure ulcers, such as obesity, poor nutritional status, decreased hemoglobin level, immobility, infection, incontinence, and fractures.

VSS before and after procedure stable (see flow sheet). Emotional support given to pt. qxd 2/10/05 6:04 PM Page 36 36 Documenting everyday events Thoracentesis When assisting with thoracentesis, assess the patient for any sudden or unusual pain, faintness, dizziness, or vital sign changes. Report these observations to the physician immediately, and document them as soon as possible. Also document: Ⅲ time and date of the procedure Ⅲ name of the physician performing the procedure Ⅲ amount and quality of fluid aspirated Ⅲ fluid specimens sent to the laboratory for analysis Ⅲ patient’s response to the procedure.

Cardiac monitor showing NSR at a rate of 70, O2 sat. via continuous pulse oximetry 99%. Within 1 min of testing, heart rate 150 with PVCs, and O2 sat. dropped to 95%. Pt.

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