Lesson 1: Documenting and Reporting PDF

[State's] inherent obligation to ensure that LESSON 1: DOCUMENTING AND personal information in information and REPORTING communications systems in government and in the private sector...

[State's] inherent obligation to ensure that LESSON 1: DOCUMENTING AND personal information in information and REPORTING communications systems in government and in the private sector are secured and Discussion protected" Informal oral consideration of a Ethical and Legal Considerations subject by two or more health care personnel Ensuring confidentiality of computer records Report - Personal password that is not to be shared Oral, written, or computer-based - Never leave a computer terminal communication intended to convey unattended after logging on information to others - Do not leave client information Record displayed on the monitor where others may see it Also called chart or client record Ensuring confidentiality of computer Formal, legal document that records provides evidence of a client's care - Shred all unneeded computer- Can be written or computer based generated worksheets Process of making an entry on a - Know facility's policy and procedure client record is called recording, for correcting an entry error charting, or documenting - Follow agency procedures for documenting sensitive material Ethical and Legal Considerations (ex.Diagnosis ) - IT personnel must install a firewall to Confidentiality of all patient protect server from unauthorized information access Client's record protected legally as a private record of client's care Purposes of Client Records HIPAA (Health Insurance Portability and Accountability Act of 1996) Communication regulations updated on April 14, - Prevents fragmentation, repetition, 2003 and delays in care Responsibility in using records for Planning client care the purpose of education and - Nurses use baseline and ongoing research data to evaluate effectiveness of the care plan. In 2012, the Philippines passed Republic Auditing health agencies Act No. 10173, or the Data Privacy Act of - Review client records for quality 2012 (DPA) "to protect the fundamental assurance purposes human right to privacy of communication Research while ensuring free flow of information to - Treatment plans for a number of promote innovation and growth [and] the clients with the same health  problems can yield information Advantage helpful in treating other clients Education Encourages collaboration Reimbursement Easier to track status of problems - From the federal government (Medicare) Disadvantage - Must contain correct DRGs Vigilance required to maintain up-to- (diagnosis related group) date problem list Legal documentation Assessments and interventions must - Admissible in court as evidence be repeated when more than one unless client objects because problem exists information client gives to primary care provider is confidential The POMR has four basic components Health care analysis - Identify agency needs such as 1. Database overutilized and underutilized hospital services All information known about the client when the client first enters the + Copies of the chart lng ang ibigay, not health care agency (PA, Dx test. Hx, original family data) DOCUMENTATION SYSTEM 2. Problem list 1. Source-Oriented Record Listed in order in which they are identified and others resolved Traditional client record Each discipline makes notations in a 3. Plan of care separate section (order form. history sheet, NN) Made with reference to active Information about a particular problems problem distributed throughout the Generated by individual who lists the record problems (NCPs,Med.Care plans) Narrative charting - Written notes that include routine 4. Progress notes care, normal findings, and client Made by all health professionals problems involved in a client's care - Often chronologic Uses SOAP, SOAPIE, SOAPIER 2. Problem-Oriented Medical Record documentation Data arranged according to client SOAP problem (Problem list) S - Subjective data consist of information Health team contributes to the obtained from what the client says problem list, plan of care, and progress notes. O - Objective data consist of information Focus on abnormal or significant that is measured or observed by use of the findings senses Incorporation of: A - Assessment is the interpretation or conclusions drawn about the subjective and - Flow sheets objective data - Standards of nursing care - Bedside chart forms P - The plan is the plan of care designed to resolve the stated problem Agencies develop standards of nursing practice. I - Interventions refer to the specific interventions that have actually been 6. Computerized Documentation performed by the caregiver Electronic health records (EHRS) E - Evaluation includes client responses to Developed to manage volume of nursing interventions and medical information treatments. This is primarily reassessment data. Used by nurses to: R- Revision reflects care plan modifications - Store client's database, new data suggested by the evaluation. Changes may - Create and revise care plans be made in desired outcomes, interventions, - Document client's progress or target dates. Information easily retrieved Speech-recognition technology 3. PIE - Nurse must be alert and aware of others who might hear the dictation. 4. Focus Charting Possible to transmit information from one care setting to another Focus on client concerns and strengths Case Management Model Progress notes organized into DAR format Quality, cost-effective care delivered within established length of stay Data Uses multidisciplinary approach, critical pathways. Assessment phase Incorporates graphics and flow sheets Action Variance (A goal that is not met) Documentation of variances Planning and implementing phase includes: Response - Actions taken to correct the situation - Justification of actions taken Evaluation phase Documenting the Nursing Process 5. Charting by Exception  Describe client's ongoing status in Flow Sheets record Reflect the full range of the nursing Graphic record process - Body temperature, pulse, respiratory rate, blood pressure, weight, other Admission Nursing Assessment significant clinical data Intake and output Comprehensive admission - All routes measured and recorded assessment when client first Medication administration record admitted to nursing unit (Ex.Initial - Date of order, expiration date, name database, hx,nsg. Assessment) and dose, frequency and route of Ongoing assessments and administration, nurse's signature reassessments recorded on flow Skin assessment record sheets or nursing progress notes - Such as the Braden Assessment Nursing Care Plans SBAR Types Situation Background Traditional care plans: Written for Assessment each client Recommendation Standardized care plans: Based on institutions' standards of practice General Guidelines for Recording Kardexes 1. Date and timeConventional a.m./p.m. or 24-hour Concise method of organizing and 2. Timing recording data - No recording before providing care Series of cards kept in a portable 3. Legibility index file or on computer-generated - Must prevent interpretation errors form 4. Permanence Information quickly accessible - Entries made in dark ink Pertinent information about the client 5. Accepted terminology arranged in sections - When in doubt, write the term out - Allergies fully - List of medications including IV fluids - May be different between agencies Pertinent information about the client 6. Correct spelling arranged in sections - Look up in dictionary or resource - List of daily treatments and book if unsure procedures 7. Signature - List of diagnostic procedures - Includes name and title - Physical needs to be met 8. Accuracy - Stated goals - Before making an entry, check that the chart is the correct one + kardex pde pencil, chart need ballpen 9. Sequence  - Document events in the order they occur Two basic types 10. Appropriateness - Simple (sugar) or complex - Record only information that pertains carbohydrates (starch,fiber) to the client's health and care 11. Completeness Types of carbohydrates - Include care that is omitted because Sugars (simple) of client's condition, refusal - Monosaccharides 12. Conciseness Glucose (the most - No extra details abundant), Fructose, & - Client's name and "client" omitted Galactos 13. Legal prudence - Disaccharides - Usually viewed by juries and Starches (complex) attorneys in court as a legal - Polysaccharides document Fiber (complex) - supplies roughage or bulk to LESSON 2: NUTRITION diet. Nutrition - All interactions between organism Carbohydrate digestion and food it consumes Nutrients Major enzymes ptyalin (salivary - Organic and inorganic substances amylase), pancreatic amylase, and required for body function disaccharides Nutritive value End products are monosaccharides. - Nutrient content of a specified Normally absorbed by the small amount of food intestine Macronutrients (need in large amount) Carbohydrate metabolism ➔ Water (most basic nutrient need) The body breaks carbohydrates into ➔ Carbohydrates (fuel, energy) glucose. ➔ Protein ○ Maintains blood levels ➔ Fats ○ Provides a ready source of ➔ Minerals and vitamins required in energy hundreds of grams Micronutrients (required in small Storage and conversion amounts) Used, or stored as glycogen or fat ➔ Vitamins ➔ Minerals Protein (CHON) ➔ Required in milligrams or ➔ for tissue growth and maintenance micrograms ➔ Essential amino acids ◆ Cannot be manufactured in Carbohydrates the body - Carbon (C), hydrogen (H), oxygen ◆ histidine, isoleucine, leucine, (O) lysine, methionine,  phenylalanine, tryptophan, Vitamin threonine, and valine ○ Organic compounds that ◆ Arginine cannot be manufactured by ➔ Nonessential amino acids body ◆ Those that the body can ○ Needed to catalyze manufacture metabolic processes ◆ alanine, aspartic acid, ○ Water-soluble cystine, glutamic acid, C, B complex glycine, hydroxyproline, Needed daily proline, serine, and tyrosine. ➔ Complete proteins Vitamin ◆ contain all of the essential Fat-soluble amino acids plus many ○ A, D, E, and K nonessential ones ○ Can be stored ➔ Incomplete proteins ◆ lack one or more essential Minerals amino acids Macrominerals (require daily over 100 mg) Protein metabolism (3 Activities) ○ Ca, P, Na, Mg, CI, S Anabolism Microminerals (require daily less ○ Building tissue than 100 mg) Catabolism ○ Breaking down tissue ○ Fe, Zn, Mn, I, , F, Cu, Co, Cr, Maintaining Nitrogen balance Se ○ degree of protein anabolism Energy Balance and catabolism Relationship bet. energy derived ○ reflects the status of protein from food and energy used by body nutrition in the body Energy intake Lipids ○ Caloric value organic substances that are greasy Amount of energy and insoluble in water but soluble in nutrients or foods alcohol or ether supply to the body ○ Fats and oils A person's energy Fatty acids balance is determined ○ Saturated (LDL) bad by comparing his or cholesterol her energy intake with ○ Unsaturated (HDL) good energy output. cholesterol Calorie (unit of heat energy) Simple or compound lipids ○ Small calorie (c, cal) ○ Glycerides (most common ) the amount of heat ○ Triglycerides required to raise the Cholesterol Temp of 1 g water, 1 ○ Needed to create bile acids, degree C synthesize steroid hormones  ○ Large calorie (Calorie, - Optimal weight kilocalorie [Kcall) recommended for optimal amount of heat health energy required to Body Mass Index (BMI) raise Temp 1 g water, 15 to 16 degrees C Considered more reliable indicator by health Kilojoule (kJ) *metric system professionals ○ One Calorie (Kcal) equals ○ 4.18 kilojoule Percent body fat Energy freed in food metabolism Maintaining a healthy or ideal body ○ Carbohydrates (4 Cal/g) weight requires a balance between ○ Protein (4 Cal/g) the expenditure of energy and the ○ Fat (9 Cal/g) intake of nutrients. ○ Alcohol (7 Cal/g) Body Mass Index (BMI) ENERGY OUTPUT Considered more reliable indicator Metabolism refers to all biochemical and by health professionals physiological processes by which the body Measure the person's height in grows and maintains itself. meters, e.g., 1.7m (1 meter =3.3 ft, Metabolic rate is normally expressed in or 39.6 in.) terms of the rate of heat liberated during Measure the weight in kilograms, these chemical reactions e.g., 72 kg (1 kg = 2.2 pounds) Calculate the BMI using the Basal Metabolic Rate following formula: weight (kg) / Is the rate at which the body height (m2) metabolizes food to maintain the energy requirements of a person Factors Affecting Nutrition who is awake and at rest. Development The energy in food maintains the ○ Periods of rapid growth basal metabolic rate of the body and require an increase in provides energy for activities such nutrients as running and walking Sex ○ differ for men and women Resting Energy Expenditure because of body composition Is the amount of energy required to and reproductive functions. maintain basic body functions. Ethnicity and Culture Calories required to maintain life ○ Traditional foods healthy individuals had an estimated ○ Do not use "good food, bad 1 cal/kg of body weight/h for men food" approach and 0.9 cal/kg/h for women Beliefs about food ○ Fads (certain foods have BODY WEIGHT AND BODY MASS special powers or certain STANDARDS foods are harmful. Ideal Body Weight (IBW) Personal Preference  ○ Related to familiarity. 2. Toddler 1-2 years ○ People develop likes and ○ Eat most foods dislikes based on ○ Adjust to 3 meals/day associations with a typical ○ Feed selves food. ○ Deciduous teeth allow range ○ Textures play a great role in of foods food preferences. 3. Preschooler 3-5 Lifestyle ○ Adult foods ○ Convenience vs. preparation ○ May require snacks ○ Muscular activity affects 4. School-Age Child 6-12 metabolic rate more than any ○ Balanced diet of about 2400 other factor Kcal ○ Mental activity, which ○ Protein-rich food for requires only about 4 Kcal breakfast to sustain school per hour, provides very little work metabolic stimulation. ○ Teach child about healthful Economics eating ○ Availability of meat, fresh ○ Poor eating habits lead to vegetables. obesity ○ What, how much, and how 5. Adolescent 10-19 often an individual eats are ○ Increased need for nutrients frequently affected by and calories, calcium socioeconomic status. ○ Teach healthy lifelong eating Health habits ○ Medications ○ Risk for eating disorders ○ Therapy Anorexia nervosa ○ Dysphagia ( Difficulty Bulimia swallowing) 6. Young Adult 20-39 Alcohol Consumption ○ Continue to eat a healthy diet Advertising with special attention to Psychological Factors protein, calcium, and limiting cholesterol and caloric intake Nutritional Variations Throughout the ○ Two or three liters of fluid Life Cycle should be included in the 1. Neonate to 1 Year daily diet ○ Demand feeding 7. Middle-Aged Adult 40-59 Child fed when ○ Postmenopausal women hungry need to ingest sufficient ○ Regurgitation calcium and vitamin D to Does not usually reduce osteoporosis result in deficiency ○ Antioxidants such as vitamin ○ Iron deficiency anemia A, C, and E may be helpful in Anemia reducing the risk of heart ○ Bottle mouth syndrome disease in  8. Older Adults 60 or older RECOMMENDED DIETARY INTAKE ○ require the same basic The effect of illness or injury (increasing the nutrition as the younger adult need for nutrients) and the variability among ○ fewer calories are needed individuals within any given subgroup are because of the lower not taken into account in the Dietary metabolic rate and the Reference Intake. decrease in physical activity. Food labeling is required for most Physical changes prepared foods, such as breads, ○ tooth loss cereals, canned and frozen foods, ○ impaired sense of taste and snacks, desserts, and drinks. smell Nutrition labeling for raw produce (fruits and vegetables) and fish is STANDARDS FOR A HEALTHY DIET voluntary. Daily food guides help people get the Based on a 2000-calorie diet, a serving with nutrients they need and plan their meals. 100 calories is considered moderate and They focus on different food groups to meet 400 calories high. nutritional requirements. Examples include the 2015–2020 Dietary Guidelines for VEGETARIAN DIETS Americans and the USDA's MyPlate. Individuals may become vegetarians for economic, health, religious, ethical, or DIETARY GUIDELINES FOR AMERICANS ecologic reasons The USDA publishes a new dietary guide There are two basic vegetarian diets: every five years, with the 2015–2020 edition those that use only plant foods offering advice for a balanced and (vegan) nutrient-rich diet. those that include milk, eggs, or These guidelines support the Healthy dairy products. People 2020 goals, which include: Other types of vegan diets Reducing obesity rates among Lacto-ovo vegetarianism - allows the adults (to 30.5%) and children (to consumption of animal products 14.5%). such as dairy and eggs Increasing the number of people Ovo-vegetarian - does not eat meat, who consume less than 2300 mg of fish, or dairy products sodium daily. Lacto-vegetarian - abstains from the Preventing inappropriate weight consumption of meat but consumes gain. dairy. Reducing calorie intake from solid Pescatarian - a person who eats fish fats (target: 14.2%) and added Flexitarian - changes in between. sugars (target: 9.7%) for those 2 Vegetarian diets can be nutritionally sound if years and older. they include a wide variety of foods and if In May 2011, First Lady Michelle Obama proper protein and vitamin and mineral introduced the MyPlate icon as a simple supplementation are provided. reminder of how to implement the dietary Because the proteins found in plant foods guidelines. are incomplete proteins, vegetarians must eat complementary protein foods to obtain ○ assessed by measuring all of the essential amino acids serum protein levels such as albumin and transferrin ALTERED NUTRITION Malnutrition lacks necessary or appropriate ASSESSMENT food substances. Overnutrition happens Nursing history when you consume more calories than Age, sex, and activity level needed, leading to excess fat storage. An Difficulty eating (e.g., impaired individual is considered overweight with a chewing or swallowing) BMI between 25 and 29.9, and obese with a Condition of the mouth, teeth, and BMI over 30. presence of dentures Undernutrition happens when you don’t Changes in appetite and weight get enough nutrients due to not eating Physical disabilities that affect enough, poor digestion, or absorption purchasing, preparing, and eating issues. Problems like difficulty preparing General health status and medical food, lack of knowledge about nutrition, or condition medical conditions can lead to Medication history. undernutrition. It often results in weight loss, General health status and medical weakness, slower healing, more infections, condition and longer hospital stays. Initially, the body Medication history. uses stored carbohydrates for energy, but these reserves only last about a day before Nutritional Screening it starts using body protein. an assessment performed to identify Protein-calorie malnutrition (PCM) is clients at risk for malnutrition or common in starving children from poor those who are malnourished. countries but also affects people with Clients found to be at moderate or long-term calorie deficiencies, such as high risk are followed with a those with cancer or chronic diseases. PCM comprehensive assessment by a is marked by low levels of proteins in the dietitian. blood, weight loss, and noticeable loss of muscle and fat. COMPONENTS OF A NUTRITIONAL Protein stores in the body are generally ASSESSMENT divided into two compartments: Anthropometric Data somatic - largely of skeletal muscle noninvasive techniques that aim to mass quantify body composition ○ assessed by conducting ○ Height anthropometric ○ Weight measurements such as the ○ Ideal body weight mid-arm circumference ○ Usual body weight Visceral - includes plasma protein, ○ Body mass index hemoglobin, several clotting factors A skinfold measurement is hormones, and antibodies. performed to determine fat stores.  - includes subcutaneous tissue portion sizes, over a specified but not the underlying period, usually 3 to 7 days. muscle. 4. Diet History: A thorough assessment Mid-arm circumference (MAC) is a including a 24-hour recall, food measure of fat, muscle, and skeleton frequency record, and food diary, Mid-arm muscle area (MAMA) is plus an evaluation of medical and an estimate of lean body mass, or psychosocial factors. skeletal muscle reserves. Fluctuations in hydration status that DIAGNOSING often occur during illness can Nursing diagnoses for nutritional problems influence the accuracy of results. include obesity, excess or insufficient dietary Biochemical (Laboratory) Data intake, and overweight. Nutritional issues ○ Serum Proteins can also impact other areas, such as Albumin constipation from low fluid and fiber intake Transferrin or altered self-esteem due to obesity. Total iron binding capacity PLANNING ○ Urinary tests Major goals for clients with or at risk for Urea nutritional problems include the following: ○ Total lymphocyte count Maintain or restore optimal nutritional status Promote healthy nutritional practices Dietary data Prevent complications associated Includes the following: with malnutrition Eating patterns, habits Decrease weight Food preferences Regain specified weight Frequency, type, and quantity of food consumed IMPLEMENTING Social, economic, ethnic, religious Nursing Interventions to promote optimal factors nutrition for hospitalized clients as often Living and eating companions, etc. provided in collaboration with the primary Four possible methods for collecting care provider who writes orders and the dietary data: dietitian who informs clients about special 1. 24-Hour Food Recall: The client diets. lists all food and drinks consumed Reinforce information presented by over a typical 24-hour period at dietitian home. Create an atmosphere that 2. Food Frequency Record: It shows encourages eating types of foods eaten but not Provide and assist with eating as amounts. It can be focused on needed specific nutrients like fat or fiber if Assisting clients with meals needed. Be sensitive to client's feelings of 3. Food Diary: A detailed log of all food embarrassment and drink consumed, including ○ Help client to feed self  Ask order in which client would like ○ Liquid may be added to the to eat food, which is then blended Use normal utensils whenever to a semisolid consistency possible Diet as tolerated Stimulating the appetite ○ ordered when the client’s Decrease in food intake is often appetite, ability to eat, and accompanied by decrease in fluid tolerance for certain foods intake. may change. Short-term decrease is not a ○ the diet may be advanced to problem, but over time it leads to a full liquid, light, or regular nutritional problems. diet. Determine reason for lack of Modification for Disease appetite, then deal with problem ○ Many special diets may be prescribed to meet ASSISTING W/ SPECIAL DIET requirements for disease Alterations in the client’s diet are often processes or altered needed to treat a disease process. Diets metabolism are modified in one or more of the following ○ Some clients must follow aspects: texture, kilocalories, specific certain diets (e.g., the nutrients, seasonings, or consistency. diabetic diet) for a lifetime. Clear Liquid Diet Dysphagia ○ limited to water, tea, coffee, SYMPTOMS OF DYSPHAGIA clear broths, ginger ale or Choking on food/drink other carbonated beverages, Coughing during/after strained and clear juices, and swallowing plain gelatin. Coughing/vomiting blood ○ major objectives of this diet Having a weak/soft voice are to relieve thirst, prevent Aspirating (getting food into dehydration, and minimize your lungs) stimulation of the GI tract. Excessive saliva or drooling Full Liquid Diet Difficulty chewing ○ contains only liquids or foods Trouble moving food to the that turn to liquid at body back of your mouth temperature, such as ice Food sticking in your throat cream. ○ is monotonous and difficult Enteral Nutrition for clients to accept Enteral - Alternative feeding Soft Diet methods that ensure adequate ○ is easily chewed and nutrition through GI system digested. methods. ○ A pureed diet is a Provided when the client cannot ingest modification of the soft diet. foods or the upper GI tract is impaired and the transport of food to the small intestine is interrupted. Enteral Access Devices Enteral Access is achieved by means of nasogastric or nasointestinal (nasoenteric) tubes, or gastrostomy or jejunostomy tubes. Nasogastric tube is inserted through one of the nostrils, down to the nasopharynx and into the alimentary tract. - are used for feeding clients who have adequate gastric emptying, and who require short term feedings.