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Elderly

The document discusses guidelines for effective nursing documentation for an elderly patient case. It outlines principles such as using objective, measurable terms; documenting the patient's exact words; recording time and dates accurately; and not leaving any fields blank. It then presents a case of a 78-year-old man living at home with his wife who is sick with fever, cough, rapid breathing, and other concerning symptoms and has not been given medication.

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Framita Rahman
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42 views12 pages

Elderly

The document discusses guidelines for effective nursing documentation for an elderly patient case. It outlines principles such as using objective, measurable terms; documenting the patient's exact words; recording time and dates accurately; and not leaving any fields blank. It then presents a case of a 78-year-old man living at home with his wife who is sick with fever, cough, rapid breathing, and other concerning symptoms and has not been given medication.

Uploaded by

Framita Rahman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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DOCUMENTING THE HEALTH HISTORY,

PHYSICAL EXAMINATION FINDINGS, AND


DEVELOP NURSING CARE PLAN IN RELATION
TO:
ELDERLY CASE

_ Framita Rahman_
Define d o c u m e n t a t i o n in N u r s i n g
Practice

• Documentation in Nursing Practice is anything written or


electronically generated that describes the status of client on the
care or services given to that client (Perry, A/ G., Potter, P.A. , 2010)

• Nursing documentation refers to written or electronically client


information obtained through the nursing process, (Associationof
Registered Nurses of Newfoundland and Labrador , 2010)

• Document is an integral part of nursing practice and professionalof


nursing care rather than something that takes away from patient
care.

• Document is not optional.


Core principles o f effective
d o c u m e n t a t i o n in Nursing
Practice

Nursing documentation must provide an accurate


and honest account of and what events occurred as
well as identify who provided the care.
Good documentation has 6 important
characteristics.
• Descriptive objective information about what the
nurse sees, hears, feels, smells and think

• Vague terms like seem or apparently

• Includes objective signs of problems

• Subjective data is documented in client’s exact


words within quotation marks
• Use of exact measurement establishes accuracy

• e.g. Intake of 400ml of water thenwriting


adequate amount of water
• Condition change

• Patient’s responses especially unusual, undesired or


ineffective response.

• Communication with patient family

• Entries in all spaces on all relevant assessment form. Use


N/A or other designation per policy for items that do apply
to your patient.
N/A
• Do not leave blank
• Document date & timeof each recording

• Record time in conventional manner (e.g. 9:00am to


6:00pm or according to the 24 hoursclock)

• Avoid recording in advance (this practice is illegal


falsification of the records contributes to errorsand
confusion and threatens patient safety.

• Client’s name, the word can be omitted


• Recording need to be brief as well as complete to
save time and communication
• Using black pen, clear enough to be
read, readable particularly handwriting

• Any mistakes occur while recording draw a line


through it and write above or next to originalentry
with your initial or name.
CASE
A 78-year-old man lives at home with his 70-year-old wife.
Clients live on stilts. Thecommunity health nurse came to
the client's house and found that grandfather was sick with
a fever accompanied by coughing, his wife said the client
had not been given medicine. The results of the
temperature assessment were 39 ° C, felt warm, and
looked coughing, breathing 16 x / min, TD 110/70 mmHg,
dry lips, and the client looked thin. Coughing up phlegm,
since 4 days ago, heard the sound of Rhonchi.

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