Natcep day 4

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NATCEP Day FourResident Comprehensive

Assessment, Care Plan and Conference

OB

JEC

TIV

ES

State the purpose of a resident comprehensive assessment

State the purpose of a resident care plan

State the purpose of the resident care conference

Identify the role of the STNA in the care planning conference 

Describe the STNA’s role in gathering and documenting information

CA

RE P

LA

N &

CA

RE

CO

NFER

EN

CE

Identifies specific therapeutic actions for resident based on their individualized need

STNA should attend care conferences at periodic intervals to gain insight into caring for residents with emotional needs

PU

RP

OS

E O

F C

AR

E P

LA

N

Resident care problems and strengths to be addressed by the health care team are identified and ways to help the resident are identified.

Resident care plans are communicated to all 3 shifts and to all staff involved in the resident’s care to ensure consistency.

 

RO

LE O

F T

HE N

UR

SE

AID

E IN

TH

E C

AR

E

PLA

NN

ING

PR

OC

ESS

A member of the care team.

Provides/gathers data and information that will be helpful for the assessment and care planning process.

NU

RS

E A

IDE R

OLE

IN G

ATH

ER

ING

&

DO

CU

MEN

TIN

G

INFO

RM

ATIO

N

Vital Signs› Temperature, Pulse,

Respirations Skin Care

› Bathing, Turning & Positioning

Elimination› Urine, Bowel Movements

Ambulation› Walking, devices to help

walking Mobility

› Independent?› Staff Assistance?

NATCEP Day FourMedical Record

OB

JEC

TIV

ES

Identify the purpose of a medical record

Identify ways the NA can contribute to the medical record

Identify common medical abbreviations

Identify the proper methods of documentation

PU

RP

OS

E O

F A

M

ED

ICA

L R

EC

OR

D

Chronological record of the resident’s condition and care.

Legal record of medical and nursing care.

Way for the health care team to communicate information about the person.

Can be used as court evidence of a person’s problems, treatment and care.

MED

ICA

L R

EC

OR

D:

STN

A C

ON

TR

IBU

TIO

N

Observing the resident Reporting changes to

the nurse in charge Recording information

according to facility policy.

Participating in care conferences.

CR

ITIC

AL N

OTE

Always remember – if it is not documented, it was not done.

GEN

ER

AL R

ULES

: CH

AR

TIN

G

Use ink Legible & neat Agency-approved

abbreviations Correct spelling,

punctuation & grammar No erasing or white out Agency policy for error

correction Sign with first initial,

last name, and title

GEN

ER

AL R

ULES

: CH

AR

TIN

G

Military Time

GEN

ER

AL R

ULES

: CH

AR

TIN

G

Never skip lines No spaces between

entry and signature Fill in empty space with

a line Record what you did

and/or saw Chronological order Use direct quotes from

resident with quotation marks

Record safety measures Correct chart

CO

MM

ON

DO

CU

MEN

TS

TH

AT N

UR

SE A

IDES

C

OM

PLETE

I & O Sheets Meal Records Restorative Records Vital Sign Sheets &

Graphic Records ADL Records Bowel & Bladder

Program Records Examples in Chapter 6

beginning on page 66

NATCEP Day FourObservational Skills

HO

W O

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ER

VA

NT A

RE

YO

U?

Do your friends tell you that you notice EVERTHING – or maybe NOTHING?

Observation is critical in your role as a nursing assistant

Key objectives:› Discuss the importance of

observation› Describe various observation

techniques› Identify observations to be

made during resident care› Demonstrate how to report

and record observations

LET’S

FIN

D O

UT. . . .

WH

AT D

ID Y

OU

SEE?

Are there cars parked on the sides of the road?

What color is the pickup truck driving in the road?

Any minivans around? What does the blue sign

say? What’s the speed limit? Are there any

pedestrians on the road?

WA

NT T

O T

RY

AG

AIN

?

WH

AT D

ID Y

OU

SEE?

How many cars did you see?

How many trucks? How many of the

vehicles in the parking lot can you describe?

LA

ST O

NE. . . . .

WH

AT D

ID Y

OU

SEE?

How many vehicles where in the intersection?

Across the street, are there any vehicles parked on the side?

Can you describe at least one of the vehicles driving through the intersection?

Are there any potential witnesses?› If so, what was the witness

doing?› If so, where was he or she?

What was the speed limit? Was there anyone parked in

the first parking spot?

WH

Y IS

OB

SER

VATIO

N

IMP

OR

TA

NT?

Your observations can alert you to changes in the resident’s condition

Observations should be made continuously during resident care

BE ALERT at ALL TIMES

WAY

S T

O O

BS

ER

VE

SEE› What might we see?

FEEL› What might we feel?

HEAR› What might we hear?

SMELL› What might we smell?

OB

SER

VA

TIO

NS

OF N

OTE

What is the resident’s general appearance?

Is the resident alert, confused, drowsy?

What is their activity level? What is the color of his/her

skin, mouth, fingernails? What is the condition of

his/her breathing? How does the resident

manage eating, drinking, elimination?

Has there been a change in his/her sleeping habits?

What is his/her mood or behavior?

TY

PES

OF D

ATA

Objective: Signs› Observed through the 5

senses: seen, felt, heard, smelled or tasted

Subjective: Symptoms› Things the resident tells

you that you cannot observe through the senses

WH

AT T

YP

E O

F D

ATA

?

Breathing is labored (difficult)› Objective

Chest pain› Subjective

Pulse › Objective

Dark urine› Objective

Nausea› Subjective

Sweating› Objective

Breath is “fruity”› Objective

Fearful› Subjective

REP

OR

TIN

G &

R

EC

OR

DIN

G

Changes in the resident’s condition are reported to the nurse immediately.

Observations are reported and recorded exactly as seen, felt, heard or smelled, or in the resident’s own words.

NATCEP Day FourMeeting the Basic Emotional

Needs of Residents

OB

JEC

TIV

ES

Identify basic emotional needs of the residents in a LTCF

Identify actions the STNA can take to meet the emotional needs of the resident

Recognize common behaviors displayed when emotional needs are not met

Describe therapeutic interventions the STNA may use in response to a resident’s behavior

Describe the role of the care plan and care conference in responding to a resident’s behavior

MA

SLO

W

Human Psychologist Believed that

individuals are controlled by their values and the choices they make

Model of human needs› Hierarchy of Needs

HIE

RA

RC

HY

OF N

EED

S

Physiological Needs› Survival

Food Water Air Sleep Sex

Physiological Needs

HIE

RA

RC

HY

OF N

EED

S

Safety› Security, stability,

keeping us from harm Physical Security Shelter Safe environment

Physiological Needs

Safety

HIE

RA

RC

HY

OF N

EED

S

Love/Belonging› Need to give and receive

love and affection Friendship Family Sexual intimacy

Physiological Needs

Safety

Love/Belonging

HIE

RA

RC

HY

OF N

EED

S

Esteem Confidence Content Respect self and others’

respect Prestige & Power

Physiological Needs

Safety

Love/Belonging

Esteem

HIE

RA

RC

HY

OF N

EED

S

Physiological Needs

Safety

Love/Belonging

Esteem

Self ActualizationBecome what we are capable of becoming

BA

SIC

EM

OTIO

NA

L N

EED

S

Independence Promote by

› Encouraging self care› Encouraging decision

making Clothing Food Activities

BA

SIC

EM

OTIO

NA

L N

EED

S

Supportive Environment

Promote by› Physical Environment

Proper medical and dental care

Safe, comfortable clothing Rooms and halls clutter

free Protection from others

(and self, if needed)› Emotional Environment

Treat with respect, acceptance and patience

Supportive of family

BA

SIC

EM

OTIO

NA

L N

EED

S

Social Interaction Promote by

› Encouraging contact with other residents

› Encouraging contact with family and friends outside the LTCF

BA

SIC

EM

OTIO

NA

L N

EED

S

Recognition as an Individual

Promote by› Be respectful › Allow for privacy› Encouraging self

expression through crafts, reminiscing and recognizing past accomplishments

BA

SIC

EM

OTIO

NA

L N

EED

S

Self Actualization Promote by

› Respect beliefs – don’t impose yours

› Learn needs and preferences that assist

› Encouraging activities that promote self actualization

CO

MM

ON

BEH

AV

IOR

S

WH

EN

NEED

S A

RE N

OT

MET

Anger Demanding Self-centered Aggressive Withdrawl Inappropriate sexual

behavior

HO

W D

O Y

OU

RES

PO

ND

TO

BEH

AV

IOR

S?

Acknowledge frustration or frightening situations

Treat with dignity and respect Answer questions clearly and

thoroughly Keep them informed Do not keep them waiting Explain reasons for long waits Stay calm and professional Do not argue Listen – use silence Protect yourself from violent

behaviors Report inappropriate behavior

to the nurse