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NFDN 1002 - UNIT 1-5 midterm
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NFDN 1002 - UNIT 1-5 midtermNursing metaparadigm (CHENS) - ✅✅-- client & person
- health
- environment
- nursing
- social justice
Client & Person - ✅✅ -- includes sickness & wellness
- Interactive relationship between nurse
- includes biological, psychological, social & spiritual dimensions
health -✅✅ -- ideal state optimal health or total wellbeing
- overall health can be affected by psychosocial/spiritual challenges
✅✅-- internal & external environments
environment -
nursing - ✅✅-- nursing process
- view of client linked with person's environment, life, health goals
Social Justice -✅✅ -- focuses on position of social advantage of 1 individual or
social group in relation to other in society
- focus on root cause of inequities and how to solve
- addresses: human rights, equity, democracy , civil rights, capacity building, just
institutions, poverty reduction, ethical practices, advocacy etc.
Nursing Process - ✅✅ -- problem solving method
- goal is to promote health & prevent further patient problems
clients in continuing care: nursing assessments - ✅✅-includes:
- individual with cognitive challenges/impairments
- sensory deficits
- chronic disease
- co-morbidities
communication challenges - ✅✅ -- pt with speaking challenges
- unresponsive/dying pt
- cognitive challenges
- vision challenges
- hearing challenges
- linguistic challenges, language barrier
,- wrong information
- poor documentation
- failure to read the pt's medical record
how to resolve communication challenges - ✅✅ -- asking pt yes or no question
- making sure the pt is involved
- ask pt to write the answer to the question
- ask pt to bring medication for assessment
- educate family so they can make a better choice so they
are more involve
- use simple words
- don't give false reassurance
- speak verbally
- have a medical interpreter to explain what is going to happen
Documentation: Confidentiality - ✅✅ -- do not look in other pt's chart if you are not
assign to them
- do not leave pt's chart everywhere
- do not talk about the pt outside of work
Confidentiality -✅✅ -- legal, ethical obligation
- only discuss its materials with pt information to be destroyed @ the end of shift
confidentiality: Students -✅✅ -- ensure permission to view charts
- provide identification
- ensure no identifying information is out of the facility
- appropriate disposal of documents if not part of the pt's health record
Personal Information Protection & Electronic Documents Act - ✅✅-- security
systems in place
- physical security
- handling & disposing of information
Documentation - ✅✅ -Purpose:
- any written or electronically generated information which provides proof of health
care provided
- paper documents, electronic medical records, faxes, e-mails, audio or visual tapes
& images
- Assessment data
- Reassessments
- Nursing analysis, patient needs, educational priorities
- Support for goals
- Interventions planned
- Continuity of care
,- Response & outcomes of care
- Ability of patient & family to manage after discharge
Guidelines for Documentation: Electronic & Written - ✅✅ -- don't document
retaliatory or critical comments about a pt
- correct all erros promptly
- record all facts
- document as close as possible to the time of event
- DOCUMENT ONLY FOR YOURSELF (not on emergency, someone will do the
recording)
- if questionable order, record that clarification was sought (doctor prescribing
medication that is hard to read)
- avoid generalizations "Status unchanged", "had a good day"
- avoid pre-charting (charting before doing it)
- start each entry with date & time
Guidelines for documentation: Written - ✅✅-- Do not erase/apply correction
ink/scratch out errors
- Do not leave blank spaces or lines
- Record all entries legibly
CLPNA - SLIME method
- SL - Single line
- I- Initial
- M - Mistake
- E - Entry
purpose of records - ✅✅ -education
- patterns of information
communication & care planning
- clear for anyone who reads it
legal documentation
- best defence is accurate documentation
funding/resource management
- how money utilized
research
- statistical data collection
auditing & monitoring
quality control
record keeping forms - ✅✅-Admission nursing history
- Guides assessment
Flow sheets/graphic records
- Quick easy reference
, Client care summary/ kardex
- Quick reference of all that is involved with care for the client.
Workload measurement systems
- Hours of care, level of staff required
Standardized care plans
- Established guidelines for care
Discharge summary
- All information surrounding discharge
- Begins at admission
Guidelines - ✅✅ -- Factual
- Accurate
- Complete
- Current
- Organized
- Compliant with standards
Factual - ✅✅ -- objective info with supporting data
- vague terms is not acceptable
- do not use words that imply an opinion
- use its exact words for subjective data with ""
- does not reflect defamation of anyone (false statement that harms their life)
Accurate - ✅✅ -- exact measurement
- approved abbreviations vary by facility (USE CAREFULLY)
- spelling always need to be correct
- Date, Time, sign full name (first initial, last name), Designation. ex, (C Maray SPN)
- reflect accountability - only chart for you
- late entries
complete - ✅✅
-- appropriate, essential information
- NOT CHARTED = NOT DONE
Current - ✅✅ -- timely
- completed as soon as possible after event
- describe chronologically
- use military 24 hour time
Organization - ✅✅ --Logical order
- Make notes as you go to avoid missing information
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