• “What interventions reduce the incidence and severity of bed sores in residents of long-term care facili-
ties?”
• P- Elderly
• I- Bedsores or pressure ulcers
• C- None
• O- Reduction in incidence and severity of bed sores
• International Council of Nurses- Promotion of health, prevention of illness, and the care of ill, disabled,
and dying people
• American Nurse Association-Nursing is the protection, promotion, and optimization of health and abili-
ties, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis
and treatment of human response, and advocacy in the care of individuals, families, groups, communi-
ties, and populations.
,• Main concepts central to nursing: person, health, environment, nursing
• Patient is “central focus” of all definitions
– Includes physical, emotional, social, and spiritual dimensions of the patient
• Review importance of documentation of patient assessments
Identify actual and potential health problems
Make nursing diagnoses
Plan appropriate care
Evaluate patient’s responses to treatment
➢ Formats for Nursing Documentation
o Initial nursing assessment: obtained from nursing history and physical assessment
o Care plan: patient’s dx, related goals, outcomes, interventions, resolutions to problems
o Patient care summary: overview of valuable patient information such as documentation, lab and
test results, orders, medications
o Critical collaborative pathways: standardized plan of care developed for a specific patient popu-
lation with a designated dx (can include list of interventions)
o Progress notes: pt’s progress towards achieving expected outcomes… description of the status of
the problem, related nursing interventions, pt responses, and needed revisions to the POC.
o Communication: primary purpose of patient record!! Helps health care professionals from differ-
ent disciplines (who interact with patient at different times) communicate with one another
o Diagnostic and therapeutic orders: The chart contains any diagnoses, new and old, and MD or-
ders and results of diagnostic tests
o Care planning: Modify care plan based on patient’s baseline and ongoing data
o Quality process and performance improvement: Accrediting agencies, such as TJC, can review
patient records to determine if the hospital or facility is meeting it’s standards. They can review
nurse’s charting to ensure patients are receiving quality and competent care
o Research; decision analysis: Uses patient record to identify needs to promote EBP
o Education: Students and health care professionals will learn from patient’s chart
o Credentialing, regulation, and legislation: reviewers can monitor health care compliance within
the facility
o Reimbursement: Insurance (payers) need to use patient records to reimburse for health care re-
ceived
o Legal and historical documentation: Legal document in court!!! Historical document for patient
to have if needed later on
➢ Characteristics of effective documentation
o Consistent with professional and agency standards
o Complete
o Accurate
o Concise
o Factual
o Organized and timely
o Legally prudent
o Confidential***
- See 16-1 Documentation Guidelines p. 342
, ➢ Review types of nonverbal behavior which could promote improved communication
-Also known as body language
Touch- tactile sense, personal behavior that means different things to different people
-factors like age and sex play a key role
-most effective nonverbal ways to express feelings of comfort, love, affection.
security, anger, frustration, aggression, excitement, and others
Eye contact- communication begins here
-some cultures suggest respect and willingness to listen and to keep
communication open
-absence often indicates anxiety or defenselessness or avoidance of
communication
-Asian and Native American = view eye contact as invasion of persons privacy
-other cultures people are tough to avoid eye contact out of respect, or to not
make eye contact with a superior
-the eyes carry other nonverbal messages like :
-in a stare during anger
-tend to narrow in disgust
-ordinarily open wide in fear
-people who cant speak send message of anxiety with eyes
-blank stare indicates daydreaming or inattentiveness
Facial Expression- face is most expressive part of body
-can convey anger, joy, suspicion, sadness, fear, and contempt
-some people have extremely expressive face
-some mask it (makes it difficult for us to know what they’re thinking
-as a nurse you need to control your facial expressions
Posture- the way a person holds the body carries nonverbal messages
-people in good health and positive attitude usually hold their bodies in good
alignment
-depressed people likely to slouch
-provides nonverbal cues for pain and physical limitations: rigid, stiff
appearance might me indictor of tension and pain
Gait- bouncy purposeful walk carries message of wellbeing
-less purposeful shuffling gait can mean person is sad or discouraged
-certain gaits can indicate illness
-ex: people recovering from abdominal surgery walk eighty bent over and slowly
Gestures- using various parts of the body can carry numerous messages
-example thumbs up = victory
-kicking an object= anger
-wringing hands or tapping foot = anxiety or anger
-waving hands (towards ) = come on
-wave other way (away)= leave
-usually used when two people in different languages attempt to communicate
General Physical Appearance- mot illnesses cause at least some alterations in general
physical appearance
-nurses observe and evaluate
-example: person w insufficient intake of fluids has dry skin that wrinkles easy,
sunken eyes, dull in appearance, poor muscle tone
Mode of Dress and Grooming- persons clothing and grooming carry nonverbal message
-healthy people: tend to pay attention to details of dress and grooming
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