Assessment and Documentation

Head to Toe AssessmentThis is done on admission

On units every 12 hours; ICU every 4 hours

It takes 5-10 minutes.

It is done by systems

Head to Toe Assessment

Overall “look” and Vital signs

Neuro- LOC!! Awake, Oriented x 3? Equal

grips? Equal leg strength?, Pupils

Cardiovascular- Skin pink and warm, Cap

refill <3, Edema?, Pulses, Rhythm, Heart

tones

Respiratory- O2 or room air, SpO2?,

Passive or labored?, Difficult to arouse?

Lung sounds

GU- Voiding? Color, amount, clear or

cloudy, odor?

GI- Non-tender or tender, distended? , firm?, Bowel sounds,

last BM?

Skin- Temp, mottled? Pink? Cap refill? turgor, breakdown? At risk for

breakdown? Temp?

Assess at IV sites or any invasive devices

Be aware of these during assessment and document your findings

Change of status from last assessment or report is very important to document

When a new symptom emerges

• Use the patient’s own words or non-verbal cues and your observations

Patient distress

Any action taken in response to a problem (SBAR)

Critical Lab values- use the critical value note in Cerner (ADHOC) • Critical values must be called and documented

within 30 minutes

The Heart of the Matter

Where the stethoscope is placed.

Lung Assessment

◦ Clear lung sounds◦ Absent or decreased sounds –

reduced airflow or consolidation, fluid (pneumothorax, pneumonia, effusions)

◦ Wheezing – upper airways narrowed, usually expiration (Asthma)

◦ Crackles or Rales – usually inspiration fine or coarse (fluid in alveoli, atelectasis)

Lung Assessment

◦ Rhonchi – characterized by a low-pitched sounds

◦ Stridor – a high-pitched, almost whistling, sound

◦ Pleural Friction Rub – occurs when the lung is actually rubbing against the ribs

NIH STROKE SCALE

It is for all Stroke patients on admission and prior to discharge.

If the patient receives tPA, the Stroke scale is completed every 2 hours for 24 hours.

NIH STROKE SCALE (continued)

SKIN ASSESSMENT◦ SKIN ISSUES: POA ◦ Look everywhere!!! ◦ Complete admission

assessment and be sure to follow up in I-view and notes prn

◦ Complete every shift as well

SKIN ABNORMALITYDOCUMENTATION

WOUNDS

Note: you can also document a surgical incision.

PAIN ASSESSMENT• Pain is assessed on admission.

• If pain is identified on initial screening, a more detailed assessment of pain will be performed.

Assessment/Reassessment◦ Following a patient or appropriate

caretaker report of pain◦ Following an intervention intended to

relieve the pain, such as administration of a pain medication

◦ During the post procedure period◦ If a change in patient’s medical status

occurs◦ Following transfer from one Floyd care

setting to another◦ At discharge ◦ Within the hour for follow-up

Scales: Numeric, Faces, FLACC, CPOT

Numeric: 1-10 is most common

FACES: children over 3 (0 = smiling happy face, 10 = crying)

FLACC: children 2 months +, or patients unable to communicate pain

CPOT: used in critical care, includes compliance with the ventilator

Non-Pharmacological Interventions for Adult Patients

Physical Interventions

• Positioning• Massage• Heat/cold• Immobilization

Cognitive Behavior Interventions• Distraction/relaxation• Guided imagery• Patient education

Abbreviations

FLOYD has established uniform definitions for commonly utilized acceptable abbreviations and symbols.

The Pharmacy and Therapeutics committee maintains a current list of abbreviations that have been shown to compromise patient safety based on hospital and national experience.

When an unacceptable abbreviation is used, the Pharmacist or Nurse will verify the prescription order with the ordering physician.

Once an unacceptable abbreviation order is verified, a verbal order clarification will be placed.

Unacceptable Abbreviations

Use as few as possible. Adhere to the approved list.

Documentation…has a History•Florence Nightingale is considered the founder of nursing documentation

• Her guidelines: Be CLEAR, CONCISE, and ORGANIZED

•The main purpose of traditional documentation was to record whether the physician’s orders were followed and policies observed

Legal Aspects of Nursing Documentation

• Charting by exception does not allow nurses to paint a true picture of the INVALUABLE care provided to patients.

Charting should:

•Accurately describe the patient’s condition and progress

•Provide communication between staff and multidisciplinary teams

•Defend the nurse legally, if necessary

Documentation Guidelines

NEVER leave gaps

NEVER document before a procedure is done or a medication is administered

ALWAYS document any condition present on admission

ALWAYS document significant changes in patient condition

Be objective and ONLY report facts….

NEVER chart subjective thoughts or comments or bias

Documentation Guidelines When in doubt… document!

Be consistent with other providers

Document unusual events or occurrences.

DO NOT CHART “SEE INCIDENT REPORT”

Do not chart “approximate time” documentation

Late entries need to be labeled as such

Documentation should be clear, concise, and specific

Use ONLY approved abbreviations!

Examples of what to chart

Oncoming/off going shift report and

assessment

Admission/receiving, document time arrival

Leaving/returning to the floor, document time of discharge or

return to floor

Bedside procedures Initiation of blood products

Communication with healthcare providers

Patient noncompliance with

plan of care/treatment

Discharge- document time of discharge, discharge location,

and mode of transport

/

Modern day technology guidelines

Don’t use your cell phone to send patient information via text

01Do not take pictures

02Do not be on Facebook on when “on stage”

03Do not access any patient’s chart that you are not involved in the patient care and need to do your job

04

Decreasing Legal Risk

Provide the highest standard of careProvide

Document very well. Be objectiveDocument

Know your medicationsKnow

Know your policies/procedures- if you’re unsure, ask for helpKnow

Continuously assess your patient- call the physician, if neededAssess

Utilize Risk ManagementUtilize

Assessment and Documentation