Documentation in Action by Springhouse

By Springhouse

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

Coverage contains documentation for care of sufferers with quite a few ailments, issues, emergencies, advanced techniques, and problems related to sufferers, households, and different healthiness care execs. feedback are given for warding off felony pitfalls concerning 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 strategies that may quickly be universal.

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____________ Pat Sloan, RN Arrhythmias Arrhythmias occur when abnormal electrical conduction or automaticity changes heart rate or rhythm, or both. They vary in severity from mild, asymptomatic disturbances requiring no treatment to catastrophic ventricular fibrillation, which requires immediate resuscitation. qxd 2/10/05 6:04 PM Page 56 56 Documenting everyday events Ⅲ date and time of the arrhythmia Ⅲ events prior to and at the time of the arrhythmia Ⅲ patient’s symptoms and the findings of your cardiovascular assessment, Ⅲ Ⅲ Ⅲ Ⅲ Ⅲ such as pallor, cold and clammy skin, shortness of breath, palpitations, weakness, chest pain, dizziness, syncope, and decreased urine output patient’s vital signs and heart rhythm (if the patient is on a cardiac monitor, place a rhythm strip in the chart) name of physician notified and the time of notification results of a 12-lead ECG, if ordered your interventions and the patient’s response emotional support and patient teaching provided.

These reports are typically reviewed by nursing administrators charged with solving the day-to-day problems of a unit. ) ■ Challenging patient conditions Some patient conditions, such as stroke and diabetic ketoacidosis, can be just as challenging to document as they are to provide care for. This section will help you to hone in on essential documentation for some of these challenging patient conditions. Anaphylaxis A severe reaction to an allergen after re-exposure to the substance, anaphylaxis is a potentially lethal response requiring emergency intervention.

RD DRAINAGE 0 ODOR 0 VOLUME 0 INFLAMMATION 0 SIZE INFLAM. KEY Stage: I. II. III. IV. qxd 2/10/05 6:04 PM Page 52 52 Documenting everyday events Wound and skin assessment tool (continued) WOUND ANATOMICAL LOCATION (circle affected area) Anterior Left foot Posterior Left lateral Right lateral Right foot Left hand Right hand Clean wound with NSS. qxd 2/10/05 6:04 PM Page 53 Challenging patient conditions 53 DO’S & DON’TS Don’t assess the item’s value or authenticity. ” 3/18/05 1300 Admitted to room 318 with one pair of brown glasses, upper and lower dentures, a yellow metal ring with a red stone, a pink bathrobe, and a black radio.

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