Documentation Important What Question & Answer Guide (With Explanation)

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What This Question Is About

This question relates to documentation important what and requires a structured academic response.

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Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves documentation important what. A strong answer should include explanation, application, and examples.

Original Question

Why is documentation so important? What are common mistakes in Nursing Documentation? What are the elements of report writing (paper) What should you document in progress notes/nursing report? Identify errors in the following progress notes and rewrite them accurately. (NOTE: disregard that there are not patient details for the purpose of this exercise Patient 1 Anthony Galea MALE DOB 21/5/1938 Address 18 Beechwood Ave Kings Point 5421 Nil Know Allergies Dr Maceri Anthony is a resident of CPU aged care facility. He was admitted 6 months ago after he burned down his house. Anthony was rescued by fire-fighters and hospitalised for 2 weeks with smoke inhalation injury. He still has a cough. Anthony was diagnosed with Alzheimer’s disease 2 years ago. He lives alone since his wife dies 15 years ago. Anthony has 3 children, 2 live out of Sydney. His son, Michael lives about 1 hour away and visits once a week as he works long hours full time. Anthony had a home care worker to visit 2 days a week but frequently refused to allow them in as he thought they were trying to steal from him. The house was becoming very messy and Michael found food left around the house, a cockroach infestation. The garden was also overgrown as Anthony was becoming increasingly forgetful. After the fire it was decided that Anthony would require supervised care. He is able to walk independently, feeds himself when reminded and seated in the dining room. Needs supervision with hygiene, often refuses to remove his clothes. Occasionally incontinent of urine and faeces. Anthony has become increasingly confused and verbally aggressive and refusing any help from nurses. He has a medical history of hypertension, Alzheimer’s disease. Before Anthony’s diagnosis with Alzheimer’s disease he was a proud gardener since he retired from his job as a factory worker. He also loved watching the news. He has a full set of dentures which he refuses to remove for cleaning. His clothes are very loose and falling off him. Today Anthony fell over while walking to the dining room. He hit his head against the wall in the corridor. There is bruising on left arm and left knee A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR Record fluid intake and output then evaluate What is your intervention (if any)? Patient 2 Imelda Garcia FEMALE DOB 2/9/1941 Address 72 Parkland Dr Darriwall 6953 Allergy PENICILLIN Dr Said Imelda was admitted to CPU aged care facility 2 months ago after multiple hospital admissions for falls. Today Imelda is agitated and you see abrasions to her forehead and elbow. When asked she does not know how they got there. Imelda is usually a pleasant and generally happy resident. She likes to talk to the other residents. She should use a quad frame to mobilise but often refuses. Imelda is 150cm tall and 55kg Her son has visited and is angry as to why she has all these new injuries. He thinks the staff are hurting her. She wears eyeglasses all the time. She has a poor appetite and often leaves the dining room without touching her food. Imelda is continent of urine and faeces. Before she retired Imelda worked in administration for the government. She has lived alone for several years since she divorced and has 2 adult sons who visit maybe once a month. Imelda is allergic to penicillin-she develops a rash and her throat swells. Imelda has full dentures. She has a medical history of high cholesterol, anaemia and heartburn. Today Imelda has a temperature of 38.2C and has had 4 episodes of diarrhoea before breakfast A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR What are the components of a neurological assessment? When completing the Glasgow Coma Scale what questions would you ask to assess verbal response When completing the Glasgow Coma Scale what questions would you ask to assess motor response “squeeze my hands-let go of my hands” (very important as squeezing hands is a reflex, letting go means they are listening to & following instruction, use only 2 fingers ever for squeezing as they are easy to remove if person’s grip is tight/strong, squeezing your whole hand may result in an injury) “lift up your arms” “open your mouth” eliciting a pain response will also illicit motor response and your are also assessing strength of limbs On inspection of pupil reaction both of Imelda’s pupils are recorded as a “3+”. What does this indicate? How do you manage injury prevention and control? Record fluid intake and output then evaluate What is your intervention (if any)? Patient 3 Teresa Volpe DOB 15/2/1932 Address 254 Wilson Rd Cameron’s Creek 1968 Nil Know Allergies Dr Maceri Teresa, another resident of CPU, is 120kg, 155cm tall. She can move from bed with one nurse to assist to the recliner where she spends her day watching TV and eating biscuits. She can walk to the toilet and shower but often asks for the commode. During her shower you notice her ankles are very swollen, and the skin is red and flaking. Teresa is continent of urine and faeces. Teresa has a history of hypertension, Obstructive Sleep Apnoea, Osteoarthritis and Chronic Bronchitis for which she has continuous oxygen via nasal prongs at 2L/minute. Teresa has no partner or family and receives no visitors. Teresa has pain in her knees and hips. Today she starts that there was a burning, broken glass like sensation when she was urinating. A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR What are the characteristics of pain assessment? Identify at least three non-pharmacological interventions for management of Teresa’s knee pain Patient 4 Nicholas Foley DOB 27/8/1942 Address 67 Low Cres Highfield 4712 Nil Know Allergies Dr Said Nicholas is a retired high school teacher (English and history) who had a stroke 6 months ago. After 6 weeks in hospital he was transferred to CPU. Nicholas is aphasic, has a right side facial droop and there is no movement in right upper and lower limb. He has limited movement on his left side. He requires full care. Nicholas was a smoker until his stroke. He occasionally obeys commands and is unable to communicate verbally. He is visited twice a week by his partner. Today, Nicholas was coughing much more than usual after you fed him breakfast. His cough is productive. Do you need PPE? A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR Nicholas SpO2 is 90% on room air. What are your priority interventions? Nicholas is at high risk of Deep Vein Thrombosis (DVT). Define thrombus Define embolus What are two preventative measures for DVT? Nicholas is also at risk of pressure areas Identify the most common areas pressure What interventions will you implement? Patient 5 Katerina Stepic DOB 15/4/1932 Address 67A Fullerton St Ocean Heights 7885 Allergy IODINE Dr Maceri Katerina used to work as machinist in a furniture factory. She resides in CPU as she is no longer able to care for herself. Katerina was diagnosed with dementia 5 years ago. Two years ago she moved to CPU as she could no longer care for herself. She is able to walk but unable to maintain any ADL’s so requires assistance with all cares. She does not communicate verbally-makes muttering, groaning sounds. There is no eye contact. She is often found wandering out of bed especially at night. Katerina is visited by her husband every day. He helps with her lunch and dinner and takes her for walks outside in the gardens of CPU. Katerina is incontinent of urine and faeces and is occasionally resistant to hygiene. She has full top dentures. Today, you find Katerina sitting on the floor. A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR Katerina’s BP is 85/40mmHg? What do you do? Define hypertension What are common causes of hypertension? Identify non-pharmalogical interventions to correct hypertension Define hypotension What are common causes of hypotension? Identify non-pharmalogical interventions to correct hypotension Patient 6 Salma Haddad DOB 28/12/1943 Address 47 Banks Rd Northville 9653 Nil Know Allergies Dr Said Salma was admitted to CPU today. Salma does not speak English. She arrives in a bed from hospital. She presented to hospital 2 weeks ago with chest infection which has left her weak and still breathless. Salma was a full time parent to seven children. Her husband died many years ago. She was living with her daughter until she was hospitalised. The other children are not able to take care of her but they did visit regularly. Salma is in CPU for respite as her daughter is recovering from major surgery. Salma walks with a walking stick. She is able to attend to her own ADL’s with assistance. Salma has smoked cigarettes for more than 40 years and is still a smoker. The hospital transfer records show that a Multi-Resistant Organism (MRO, name unknown) was found in Salma’s sputum. Salma needs a full admission to CPU Aged Care Facility. A-E assessment What assessments do you need to perform? What documents do you need? Identify issues related to nursing care Develop a plan of care What interventions will you implement Document contemporaneously and as per legal requirements ISBAR What is the precaution you must implement for MRO’s? What PPE do you need to wear? Can you take the patient charts into their room? What do you do with the equipment you used? A family member with a long term health problem arrives to visit. What would you advise the visitor?

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