MEDICARE PART A BENEFICIARY Nursing Documentation Documentation must focus upon the conditions for which the patient is receiving skilled coverage. These conditions may have prompted the initial hospitalization, but also include the conditions that arose during their recovery in the SNF. Skilled services must be identified as rendered on a daily basis to support Medicare Part A coverage. Supportive nursing notes contain details regarding skilled treatments, observations and assessments for exacerbations of conditions, and teaching and training provided. Components of daily nursing notes include: System assessments, ADL support provided, and any pertinent data that supports a high likelihood of change in condition. Documenting the patient’s attendance and response to therapy upon return to the unit supports a team approach toward ensuring medical safety and promoting recovery. The American Nurses Association standards of nursing practice require that documentation be based on the nursing process, ongoing and accessible to all members of the healthcare team. For professional, helpful, and accurate documentation based on the requirements of your state’s Nursing Practice Act, your notes should be:
Documentation to support coverage must identify the instability or probability of a change in the patient’s condition. The presence of one or more of the following is sufficient:
Admission Note The following information should be included in all admission notes:
Example Admission Nurses Note
The initial nursing admission note should identify the mode of transportation into the facility. Nursing needs to identify that the patient arrives via stretcher/ambulance, private auto or chair car. Admission notes need to further identify how the patient transferred from the stretcher and how the removal of stretcher linens and positioning in bed occurred upon the patient’s arrival. Patient was admitted via stretcher and received extensive assist of three to move from the stretcher to the bed. Patient received extensive assist of two to position in the bed. Daily Note Supportive skilled documentation includes the following terms or phrases:
Additional guidelines for daily skilled observation and assessments of common conditions include:
The daily skilled narrative nursing note shows the critical thinking, judgment decision making by skilled nurses. It further supports why daily skilled coverage is appropriate. A complete record contains an accurate and functional representation of the individual. It must contain data regarding the status of the individual, plans of care and provides evidence of the effects of the care provided. Example Daily Nurses Note
Additional examples include:
Documentation should identify response to treatment, change in condition and changes in treatment. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goals. Medicare documentation must provide an accurate, timely and complete picture of the skilled nursing or therapy needs of the resident. Documentation must justify the clinical reasons and medical necessity for Medicare Part A coverage, the skilled services being delivered, and the on-going need for coverage. Weekly Note A weekly Medicare note by the Medicare nurse may be indicated to support skills for patients needing additional documentation. These notes would summarize outcomes of skilled observation and assessment. In conjunction with nursing education, this note can serve as a model for daily notes. Medicare notes should have the specific areas highlighted by underlining the skilled areas. Conflicts in ADL coding found throughout the medical record (nursing assistant flowsheets) can be resolved by providing clarification in a weekly Medicare note. This note is an exceptionally important note to define the reasons for skilled care. The care component worksheets can be of assist, however, it is imperative that the following are addressed:
Example Weekly Nurses Note
Nursing Note Documentation Cue Sheet Nursing documentation must focus upon the conditions for which the patient is receiving skilled coverage. These conditions may have prompted the initial hospitalization, but also include the conditions that arose during their recovery in the SNF. Medicare Reviewers use the medical review guidelines found in the Program Integrity Manual (PIM) in conjunction with the Medicare SNF coverage guidelines and policy training guidelines to make coverage decisions. All SNF’s are required by regulation to assess each patient, identify their needs, and develop an individual plan of care to meet the needs (42 CFR 483.20.) Many patients in SNF’s will require some skilled services and skilled nursing oversight to ensure that the plan of care is carried out. The documentation must “distinguish between patients who require daily skilled observation and assessment or management and evaluation and patients that require periodic skilled services on a less than daily basis and/or a supportive environment and oversight to ensure their general well being” per the PIM. Documentation to support coverage must identify the instability or probability of a change in the patient’s condition. The following Nursing Note Documentation Cue Sheet provides a guide for nursing skills to cue nursing documentation for admission note contents. Varying with each diagnosis the admission note should contain detailed information on observations and assessments performed during the admission evaluation of the patient. Identification of specific skilled assessment and observation are identified on the cue sheet. For example, new insulin dependence vs. diabetic management or medication changes. Patients admitted for psychiatric stay would also benefit from listing specific medication changes that require skilled observation and assessment due to the risk of medical complication. For example, new antipsychotic use with risk of fall, weight loss and lethargy vs. medication monitoring. NURSING NOTE DOCUMENTATION CUE Daily Medicare Nursing Note (Grid Summary) Skilled nursing services must be identified as rendered on a daily basis to support Medicare Part A coverage. Supportive nursing notes contain details regarding skilled treatments, observations and assessments for exacerbations of conditions, and teaching and training provided. Components of daily nursing notes include: System assessments, ADL support provided, and any pertinent data that supports a high likelihood of change in condition. Documenting the patient’s attendance and response to therapy upon return to the unit supports a team approach toward ensuring medical safety and promoting recovery. Fine tuned skilled nursing documentation includes key Medicare terminology to offer further support of ongoing skilled coverage. Patient’s admitted to the SNF for skilled rehabilitation services are initially hospitalized for a medical condition. It is the medical condition or complications and co-morbidities that contribute to the decline in function thus requiring skilled therapy services AND skilled nursing interventions on a daily basis. Documentation should identify response to treatment, change in condition and changes in treatment. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goals. Skilled intervention may consist of observing, assessing, educating, training, and managing the overall care of the beneficiary. Recording this intervention assists in painting an accurate portrait for clinical and financial purposes. Medicare documentation must provide an accurate, timely and complete picture of the skilled nursing or therapy needs of the resident. Documentation must justify the clinical reasons and medical necessity for Medicare Part A coverage, the skilled services being delivered, and the on-going need for coverage. The Daily Medicare Nursing Note provides an outline of required and supportive data to document on each day/shift during a Medicare Part A stay in the SNF. Space is provided on the back of each sheet for narrative notes regarding situational occurrences. DAILY MEDICARE NURSING NOTE Hospital to SNF/NF Nurse Telephone Report When a patient is admitted the pre-admission data from the hospital is vital information to continuum of care. In the case that hospital data is not forwarded the facility can obtain hospital events via the SNF nurse to hospital nurse report. While copies of the supporting documentation are most desired it may be challenging to obtain at times. It is crucial to know the dates of procedures and services provided while hospitalized. This information is vital to accurately code the MDS, reflect the medical complexity of the beneficiary, guide skilled assessments and ensures optimal reimbursement. Recent studies per the AMDA (American Medical Directors Association) have identified problems in current processes for inter-institutional patient transfers. Accompanying documentation is at times inaccurate or incomplete. Consequences of inadequate documentation range from unnecessary repetition of costly tests to serious adverse drug interactions, to falls, and worse. Valuable pre-admission data includes:
When the patient is admitted or returns to the facility without information noted above instruct nursing to review all transfer information and contact the hospital discharging nurse for details as indicated. This is an opportunity for the nurse receiving the patient to obtain data such as IV medications, fluids, oxygen, and ADL support. Record the findings of this interview in the medical record and include the name of the hospital staff member. Not only from a financial perspective is this information important but clinically it will direct skilled observations. The following form provides an outline of services and levels of care to question during the SNF nurse to hospital nurse interview. The SNF nurse should request the hospital send copies of supporting data discussed during the call. HOSPITAL TO SNF/NF NURSE TELEPHONE REPORT Medicare Team Meeting The Medicare meeting will afford the team a brief review of all the Medicare Part A, Part B and Managed care beneficiaries. Utilization of a team meeting form will keep the group focused during meetings on changes in functional status, interruptions in the number of eligible days, discharge planning and skilled needs. Discussion of the following areas should also be recorded on the Medicare Team Meeting Form:
MEDICARE TEAM MEETING Interview for MDS The interview is a critical component of the assessment process as defined by the Centers for Medicare and Medicaid Services. The RAI User’s Manual instructs to use interview equally with record review and physical assessment and observations in making coding decisions. In addition to the scripted interviews outlined in the RAI User’s Manual, staff should interview the patient about their baseline functional status and current functional status. The process for performing an accurate and comprehensive assessment requires that information about residents be gathered from multiple sources. It is the role of the individual interdisciplinary team members completing the assessment to validate the information obtained from the resident, resident’s family, or other health care team members through observation, interviewing, reviewing lab results, and so forth to ensure accuracy. Similarly, interacting with the resident and direct care staff validates information in the resident’s record. The following Interview for MDS form provides a guide for questioning staff on support provided and behaviors displayed by patients, which were observed by staff members. This interview provides an opportunity for continued discussion about the patient’s usual care habits and needs, and provides valuable input to the individualized care planning process. SAMPLE INTERVIEW FOR MDS ACTIVITIES OF DAILY LIVING Scoring ADL Performance ADL’s comprise approximately 30% of the rate of reimbursement associated with the RUG score/rate. Accuracy in ADL documentation is critical for care planning and reimbursement. The resident’s performance may vary from day to day, shift to shift, or within shifts. ADL coding is also intended to be an interdisciplinary team process. The physical assistance provided to the patient while in therapy is to be reflected in the ADL coding in Section G of the MDS. An individualized plan of care can be successfully developed only when the resident’s self-performance is accurately assessed and the amount and type of support provided to the resident by others is properly evaluated. There will be patients that are very high functioning during the day and evening shifts. The night shift documentation is extremely valuable as quite often the patient may be exhausted or with discomfort from strenuous rehabilitation programs and require a degree of assistance during this time only. Capture all resources that are utilized to care for each patient. Common misconception includes coding based upon who is doing more of the activity, which is incorrect. The key determination in the extensive and limited assist levels is weight-bearing support or total dependence in a portion of a sub-task. ADL Self Performance Code the resident’s performance over the entire shift, not including set-up. Independent: No staff intervention in the past 7 days for all episodes. Supervised: Verbal cues or visual oversight. Limited Assist: Hands on assist that includes contact guard or guided maneuvering. Contact guard, guided maneuvering, or non-weight bearing support (3 episodes in the past 7 days). Extensive Assist: Hands on assist that includes any weight bearing support or dependence in a portion of the sub-task. Weight bearing support (3 episodes in the past 7 days), full staff participation during some but not all of the observation period, or dependence in a portion of the sub-task. Total Dependence: Full staff performance or in other words, the patient did not participate whatsoever in performing the task in the past 7 days for all episodes. Most ADL Support Provided No supportSet up help onlyOne person physical assistTwo or more provided physical assist Activity itself did not occur during the entire shift Note that weight-bearing support does not indicate that the patient has a weight-bearing restriction. Weight-bearing support reflects that staff bore the weight of the patient and is the difference between lifting an extremity during the task of dressing versus guiding the limb into the sleeve of a shirt. There is not a percentage of weight supported factored into this coding. Also note that the 3 episodes or occurrences may occur during one shift alone. The RAI Manual encourages that the assessor to “engage direct care staff, from all shifts, which have cared for the resident over the past 7 days in discussions regarding the resident’s ADL functional performance. Remind the staff that the focus is on the last seven days only. Ask probing questions, beginning with the general and proceeding to the more specific.” It is with these discussions that inconsistencies can be identified and corrected. It is highly recommended that the assessor schedules time to sit with the nursing assistants while they are documenting. This will allow for review and discussion of the coding increasing the understanding of its value from a clinical standpoint. The coding of ADL’s is intended to be a measurement of actual self-performance and actual staff support. Do not code for what the resident is identified as capable of doing, code for what actually occurred. Variations in function are an expected occurrence as patients demonstrate changes day-to-day and shift-to-shift due to a variety of medical and psychological reasons. The coding of more assistance provided from one nursing assistant to another is not a reflection of a staff member’s inability to perform their job effectively. On the contrary, residents that require assist in moving towards the top of the bed benefit from the 2 person lift to preserve skin integrity and prevent injury to both resident and staff members. Nursing staff is encouraged to code the flow sheets to reflect the most support provided over the entire 8 hour shift. A patient that is capable of increased participation yet receives greater assist warrants a more in-depth assessment as to the causes of such variances. Accurate ADL coding will assist in identifying and resolving these issues. A number of factors impact ADL status:
ADL Resident Assessment Flowsheet and Positioning 2.13.18 Activities of Daily Living Continued Scoring ADL Self-Performance Respiratory Therapy Respiratory Therapy by definition includes coughing and deep breathing exercises, Incentive Spirometry, the assessment of lung sounds as well as the delivery of nebulizer therapy. The patient admitted with an active pulmonary issue is appropriate to receive these skilled assessments on a daily basis. Clinically, patients with active or high risk factors for exacerbation in conditions including COPD, CHF, ARDS, aspiration precautions or pulmonary infections including pneumonia warrant a 5-minute assessment of lung sounds q shift to assess the status of these conditions. The delivery of nebulizer therapy and instruction and Incentive Spirometry qualify the patient for the Special Care High RUG. To qualify for the Special High Care RUG, Respiratory Therapy must be delivered 7 days with at least 15 minutes per day within the look back period. Documentation of the time spent with the patient while delivering this service is mandated. Implement the following in order to accurately capture these services:
Follow State Practice Acts and ensure that staff have proven competency in this area to qualify as a “trained nurse”. Nurses are not required to have special certifications or advanced training to perform Respiratory Therapy. The RAI User’s Manual states that the respiratory nurse must be proficient in respiratory modalities either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws. The facility may use a specialized flowsheet (attached) or record the time spent with the patient on the MAR or TAR as identified below: MAR Examples TAR Example Case Examples:
RESPIRATORY THERAPY SERVICES Assessment and Documentation The RAI Version 3.0 Manual Appendix A page A-19 defines Respiratory Therapy as: Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services are for the assessment, treatment, and monitoring of patients with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, heated nebulizers, aerosol treatments, assessing breath sounds and mechanical ventilation, etc., which must be provided by a respiratory therapist or trained respiratory nurse. A respiratory nurse must be proficient in the modalities listed above either through formal nursing or specific training and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws. Respiratory Assessment Symptom Analysis: When assessing a patient’s problem, remember these areas to help the patient describe the problem. P: Provocative/Palliative What causes it? What makes it better? What makes it worse?Q: Quality/Quantity How does it feel, look, or sound, and how much of it is there?R: Region/Radiation Where is it? Does it spread?S: Severity Scale Does it interfere with ADL? How does it rate on a severity scale of 1 to 10?T: Timing When did it begin? How often does it occur? Is it sudden or gradual? How long does an episode of the symptom last? Elements of Examination:
Normal Breath Sounds & Adventitious Lung Sounds Documentation to Support Respiratory Therapy and Assessment The format for collecting assessment information is facility dependent, meaning whatever format the facility chooses, but must include these necessary elements:
RESPIRATORY DEFINITIONS Policy and Procedure – Nebulizer Therapy CORE COMPONENTS The following documentation worksheets are tools to assist in properly articulating the reason for skilled care. These sheets are organized by diagnosis and are only guides. They are not part of the medical record and should be placed in a separate binder at the nurse’s station. CORE COMPONENTS DIAGNOSIS: ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
Daily Nursing Skills: High risk for infection related to immunosuppression (low T4 lymphocyte count or low T4 toT8 ratio). High risk for ineffective individual coping related to life threatening illness, potential loss of role, decisions regarding treatment or poor prognosis for long term survival. High risk for hypoxemia related to ventilation-perfusion imbalance, pneumonia, and weakness. High risk for sensory-perceptual alteration related to neurologic involvement. High risk for social isolation, impaired physical mobility related to fatigue, weakness, hypoxemia, depression, altered sleep patterns, medication adverse affects, and orthostatic hypotension. High risk for nutritional deficit, fluid, volume deficit altered oral mucus membrane related to opportunistic infections. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: AGGREGATE OF UNSKILLED SERVICES
Daily Nursing Skills: Management and evaluation of overall plan of care to promote recovery and medical safety. Observation and evaluation of medical condition given the likelihood of change to assess for the need for modification or initiation of additional interventions with the patients treatment regimen is essentially stabilized. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: AMPUTATION
Daily Nursing Skills: Assess and evaluate for signs of complications including increased stump pain, hematoma, infection, suture/staple integrity and stump necrosis. Assess circulation of affected limb, wound care and observations, pain management, psychological manifestations of loss of limb. Signs of effective grieving of loss. Stump care, compression dressings to reduce edema and shape stump to accept prosthesis. Patient education regarding skin hygiene to prevent irritation and/or infection. Monitor nutritional intake and needs to promote healing. Educate need for dietary compliance. Pain management and safety measures post amputation. Monitoring and assessment of associated conditions that precipitated need for amputation (i.e., diabetic, PVD, injury). Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: ANEMIA
Daily Nursing Skills: To assess and evaluate cardiovascular system, signs and symptoms of blood loss, response to transfusions and signs of reaction to transfusion. Scheduling of activities to promote rest and optimize use of limited energy levels. Monitor patient for signs of excessive fatigue or shortness of breath with activities. Patients area risk for infection, hemorrhage, increased fatigue and impaired skin integrity. Patient education in medical management and signs of complications. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: ANTICOAGULATION THERAPY: SUBCUTANEOUS Patient Name: ___________________________________________ Daily Nursing Skills: Patient is at high risk or injury related to anticoagulation therapy. Risk for abnormal bleeding secondary to prolonged clotting times. Daily skilled assessment for signs of bleeding, lab work and evaluation of results, skilled monitoring with changes in dosage. Patient instruction in signs and symptoms to report to caregiver. Follow-up care. Instruction in proper administration of injections. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS
Daily Nursing Skills: Atrial fibrillation is the most common form of irregular heartbeat. Irregular heartbeats are caused by abnormal electrical activity of the heart. There is a high risk for impaired blood flow to the heart muscle and to the rest of the body. Atrial fibrillation may be caused by an underlying heart disease, such as: Problems with the heart valves, Impaired blood flow to heart muscle (ischemia), weakened heart muscle (cardiomyopathy), and damage to the heart from long-standing, untreated high blood pressure (hypertensive heart disease). Infection processes, endocrine, and pulmonary disease may cause atrial fibrillation. Anticoagulant medications may be needed to prevent blood clots and lessen the risk of stroke. Patient is at high risk for abnormal bleeding with anticoagulant therapy. Other medications can control the heart rate with increased risk for adverse drug effects. Heart failure may develop if the heart rate cannot be controlled. Atrial fibrillation often causes shortness of breath, dizziness, confusion, or lightheadedness, especially during physical activity. For this reason people with atrial fibrillation may have a decreased activity tolerance with complications related to decreased mobility. There is a high risk for stroke caused by atrial fibrillation. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CARDIOVASCULAR DISEASE
Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CAST CARE AND OBSERVATION
Daily Nursing Skills: Fracture healing starts with the bleeding, tenderness, and swelling. Assess and evaluate pain levels, skin integrity, pulses, posture, positioning in and out of bed, edema, color, odor of the affected limb and safety with mobility. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CELLULITIS
Daily Nursing Skills: Cellulitis is an infection that spreads from the skin to underlying tissue. Cellulitis is caused by bacteria that invade an area of broken skin. The most common types of bacteria are streptococcus and staphylococcus. Cellulitis also can be caused by other types of bacteria, which may affect people with impaired immune systems Infection may occur at areas where the skin has been broken, by trauma or infection. Cellulitis can cause tenderness, pain, swelling, and redness at the site of the infection, and fever and chills throughout the body. In adults, infection usually occurs on the legs, face, or arms, but can occur on other areas. Cellulitis can spread infection through the body quickly. There is a high risk for bacteremia (presence of bacteria in the blood) or sepsis (infection in the blood). Other high risk complications, such as thrombophlebitis or rarely gangrene can develop, especially in older adults. Treatment for cellulitis includes antibiotics, taken either orally or intravenously, and local skin care. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CEREBRAL VASCULAR ACCIDENT (CVA)
Daily Nursing Skills: High risk for further cerebral injury related to interrupted blood flow (embolus, thrombus, or hemorrhage), and complications from impaired physical mobility related to motor cortex or motor pathways. High risk for sensory-perceptual alteration and complications related to cerebral injury. High risk for impaired communication due to cerebral injury. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Daily Nursing Skills: High risk for respiratory failure related to ventilation-perfusion imbalance, ineffective breathing pattern related to emotional stimulation, fatigue or blunting of respiratory drive, nutritional deficit and activity intolerance related to SOB and adverse effects of medications, inactivity-resultant risk for loss of function exercise related hypoxemia, fatigue from sleep disturbance secondary to bronchodilator’s stimulant effect, SOB, anxiety, depression. High risk for S&S indicating impending exacerbation. High risk of infection related to stasis of secretions, reduced activity and decreased motility in lungs. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: COLOSTOMY
Daily Nursing Skills: High risk for stomal necrosis, complications related to the surgical procedure, bowel wall edema, retraction of stoma related to mucocutaneous separation, peristomial skin breakdown related to fecal contamination. Patient instruction in colostomy care. Troubleshooting potential complications and proper fit of appliances. Instruction in avoidance of foods that are not well tolerated. Signs if impaired coping with changes in body image. Instruction in management of control of odors, prevention of leakage to promote increased acceptance and dignity with change in body image. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: COMPRESSION FRACTURES
Daily nursing skills: Fracture may be displaced or non-displaced. Patient is at high risk related to displaced fragments that may place pressure upon spinal nerves or injure the spinal cord itself. Such pressure will result in partial or complete dysfunction of the body parts innervated from the level of injury. Patient is at high risk for neurological complications related to potential spinal cord involvement. Manifestations may include: numbness and tingling of extremities, temporary or permanent dysfunction, and changes in bowel and bladder function. Nursing interventions are geared towards maintaining stability of the fracture, preventing neurocirculatory problems, and promoting comfort; both physical and psychological. Patient may be at further risk of circulatory complications, GI complications and skin integrity compromise related to decreased physical mobility. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CONGESTIVE HEART FAILURE
Daily Nursing Skills: High risk for decreased cardiac output related to cardiac contractility, altered heart rhythm, fluid volume overload, increased afterload, cardiogenic shock, pulmonary edema, AMI, arrhythmias, thrombolytic complications, liver failure, decreased renal perfusion, increased salt and water retention, renal failure. At risk for activity intolerance due to decreased cardiac output, nocturnal dyspnea. High risk for recurrence of CHF (anticipate prolonged period of observation and assessment because there is a high risk for non-compliance with medical regimen, chronicity and complexity: low sodium diet, with increased appetite, need for changes in lifestyle, including medication, activity). Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: CORONARY ARTERY DISEASE/CORONARY Patient Name: ___________________________________________ Daily Nursing Skills: CABG is performed for significant narrowing and blockages of the coronary arteries due to coronary artery disease. CABG surgery creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscles. Potential postoperative complications may include heart attacks, arrhythmias, electrolyte imbalance, bleeding, infection, lung complications, stroke and renal complications. The daily skills of the nurse are required to observe, assess, teach, train and provide the overall management of care plan to ensure medical safety and promote recovery. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: DECUBITUS ULCERS
Daily Nursing Skills: Assess and evaluate decubitus ulcer response to treatment, signs and symptoms of infection. Local infection of wound, osteomyelitis, signs of sepsis. Control and management of pain, drainage and odors of decubitus ulcer. Skilled ulcer care, assessment for possible modification to treatment to promote healing. Nutritional intake and supports to promote healing. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. Daily
Weekly
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: DEEP VEIN THROMBOSIS (DVT)
Daily Nursing Skills: DVT is an acute, potentially life-threatening condition that necessitates hospitalization. The current standard of care for treatment is with anticoagulation therapy with Heparin followed by long-term oral anticoagulation therapy. The most common factors that lead to development of DVT are venous stasis, vessel wall injury, and hypercoagulability of the blood. Stasis can occur with incompetent valves or inactive muscles. Familial deficiencies of anticlotting factors contribute to hypercoagulation states. Risk factors for development of DVT include, age, prior history of DVT, coagulation abnormalities, and major abdominal /pelvic surgeries and orthopedic procedures of the lower extremities. Other risk factors include obesity, limb trauma, heart disease, advanced neoplasms, postthrombotic syndrome, and Estrogen and oral contraceptive use. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: DEHYDRATION
Daily Nursing Skills: Dehydration occurs when the body loses too much fluid. It also occurs with decreased intake of fluids or loss of large amounts of fluids through diarrhea, vomiting, sweating, or strenuous exercise. The body’s cells absorb fluid from the blood and other body tissues. By the time the patient become severely dehydrated, there is no longer enough fluid in the body to get blood to the organs, and the patient may begin to go into shock, which is a life-threatening condition. Medications such as antihypertensives, cathartics, and diuretics increase the risk for dehydration. Skilled nursing assessment for the early signs of dehydration is critical with conditions and diseases that cause high fever, vomiting, or diarrhea. The early symptoms of dehydration include: dry mouth, sticky saliva, and reduced urine output with dark yellow urine and change in mentation. Symptoms of moderate dehydration include: Extreme thirst. Dry appearance inside the mouth and the eyes don't tear, Decreased urination, or half the normal number of urinations in 24 hours (usually 3 or fewer urinations). Urine is dark amber or brown. Lightheadedness; relieved by lying down. Severe dehydration is life threatening. Symptoms that require emergency care (even if only one of them is present) include: Altered behavior, such as severe anxiety, confusion, or not being able to stay awake. Faintness that is not relieved by lying down or lightheadedness that continues after standing for 2 minutes. Changes in pulse rate and rhythm that is weak or rapid. Skin that is cold and clammy or hot and dry. Decreased or absence of urination. Change in level of or loss of consciousness. There is a high risk for kidney failure and circulatory collapse related to dehydration. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: ENTERAL FEEDING: NG/GASTROSTOMY/
Daily Nursing Skills: Patient is at high risk for aspiration related to placement of feeding tube, positioning and other related diagnosis prompting feeding tube placement. Daily skilled nursing for frequent and periodic checking for tube placement and monitoring of gastric residuals to prevent aspiration. Monitor effectiveness of the feeding and assess the patient’s tolerance to the tube and the feeding. Special mouth care is essential to maintain a healthy oral mucosa. Daily assessment of feeding tube site to prevent irritation or complication of infection. Assessment of weights, vital signs, pain, diarrhea and tolerance of any oral intake. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. Daily
Weekly
If patient/resident is taking oral food/fluids, document daily.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: FLUID AND ELECTROLYTE IMBALANCE Patient Name: ___________________________________________ Daily nursing skills: Elderly persons are particularly vulnerable to fluid and electrolyte disorders. The elder experiences less total body water as a result of less lean body mass and more fat. The decline in the function of vital regulatory organs and a higher incidence of chronic illnesses also increase risk factors. The elder experiences a diminished ability to reestablish homeostasis when an imbalance has occurred. Elderly persons readily become dehydrated when they experience physiologic stressors from fluid restrictions, fever, diarrhea, infections and diuretic therapy. Fluid imbalance may go unnoticed by the patient as a result of a blunted thirst sensation, swallowing difficulties, misinterpretation of the need for fluids, self-imposed restrictions secondary to fears of incontinence or frequent need to urinate. Fluid loss and electrolyte imbalance is exhibited by the elder is a variety of ways. Symptoms may include changes in behaviors, confusion, apathy, headache, thirst, dry mucous membranes, anorexia, nausea, vomiting, dry and decreased skin turgor, changes in pulse and respiration rate and rhythm, muscle weakness, diarrhea, constipation, abdominal distention and abdominal cramps. With excessive fluid loss hemoconcentration occurs, and the hematocrit, hemoglobin, BUN, and electrolyte levels are increased. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: FRACTURED HIP
Daily Nursing Skills: High risk for post operative complications related to the initial trauma injury, surgical intervention or immobility, inadequate fluid replacement, blood loss, neurovascular compromise, impaired oxygenation of tissue, compartment syndrome, pulmonary embolism, fat embolism, thrombophlebitis, aseptic necrosis of the femoral head, non-union of the affected portions, osteomyelitis, pneumonia, arthritic deformities, pressure ulcers secondary to reduced physical mobility and exacerbation of preexisting conditions secondary to surgical intervention. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: GASTROINTESTINAL BLEEDING Patient Name: ___________________________________________ Gastrointestinal Bleeding Overview: The many causes of gastrointestinal (GI) bleeding are classified into upper or lower, depending on their location in the GI tract. Upper gastrointestinal bleeding: Upper GI bleeding originates in the first part of the GI tract—the esophagus, stomach, or duodenum (first part of the intestine). Bleeding can come from ingestion of caustic poisons or stomach cancer. Most often, upper GI bleeding is caused by one of the following: Peptic ulcers, Gastritis, Esophageal varices and Mallory-Weiss tears. Lower gastrointestinal bleeding: Lower GI bleeding originates in the portions of the GI tract farther down the digestive system—the segment of the small intestine farther from the stomach, large intestine, rectum, and anus. Diverticular disease, angiodysplasia, polyps, hemorrhoids, and anal fissures most commonly cause the bleeding. Blood in the stool can result from cancers, inflammatory bowel disease, and infectious diarrhea. Daily Nursing Skills: Assess and evaluate for vomiting of blood, bloody bowel movements, or black, tarry stools. Blood may look like "coffee grounds." Assess for signs and symptoms associated with blood loss including the following: fatigue, weakness, shortness of breath, abdominal pain, pale appearance, vomiting of blood usually originates from an upper GI source. Bright red or maroon stool can be from either a lower GI source or from brisk bleeding at an upper GI source. Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Example shift note: Mrs. Smith continues to receive ongoing skilled observation and assessment for the ongoing signs/symptoms of GI bleeding. Physical therapist reported that during therapy that “Mrs. Smith seemed somewhat more lethargic today, unable to participate in her therapy and she became very pale and c/o nausea when she attempted to stand.” She required assist of 2 to transfer from wheelchair to bed and then to reposition while in bed. When she returned to her room, her VS were gathered. BP= 90/62 (baseline 136/84) and her VR= 116 (baseline 84). She refused her regular diet that had been advanced yesterday but tolerated her clear fluids. No bowel movements since yesterday and bowel sounds are present and very active. She denies nausea, cramping, abdominal pain or lightheadedness at this time. A fingerstick BG was assessed to rule out hypoglycemia. BG = 88. Dr. Noitall was informed of findings and a stat Hgb/Hct was ordered. Awaiting lab to draw blood. Will report lab results directly to MD and continue to monitor patient closely for presence of ongoing GI bleeding complications. Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: HEMIPLEGIA, HEMIPARESIS, PARAPLEGIA, QUADRIPLEGIA Patient Name: ___________________________________________ Definition: Paraplegia is paralysis in both legs, below the waist. It is usually caused by a spinal cord injury or illness. Quadriplegia is paralysis below the neck and is also usually the result of a spinal cord injury. In strokes, the paralysis is on one side of the body and is called hemiparesis when there is complete paralysis of the affected side. Hemiplegia is defined as partial paralysis or weakness on one side of the body and is the term most commonly used in stroke survivors. It is often used instead of hemiplegia even when there is complete paralysis. Daily Nursing Skills: Patient is at high risk for sensory-perceptual alterations and complications related to impairment of physical mobility from cortex and motor pathway injury. Assess and evaluate for signs and symptoms of Depression, Skin Integrity alterations, muscle atrophy with eventual contractures, immobility, weight loss, neurogenic bladder, infections. This is not an exhaustive list of risk factors. It becomes vital for the nursing team to closely monitor and report any deterioration in condition before they become acute. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
** As with any diagnosis, multi-system assessments are necessary to accurately encompass all aspects of the patient’s condition and response to treatment. Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: HYPERTENSION
Daily Nursing Skills: To assess and evaluate full vital signs, complaints of headaches, especially pulsating behind the eyes that occur early in the morning, visual disturbances, nausea and vomiting. Uncontrolled high blood pressure may damage the delicate lining of the blood vessels, which may promote the formation of plaque leading to artherosclerosis. Blood flow through the blood vessels may be reduced. Decreased blood flow, over time to certain organs can cause damage leading to heart disease, heart attack, renal failure, peripheral vascular disease, retinopathy and stroke. Nursing to monitor effectiveness of antihypertensive regimen, titration of medication and parameters to hold medications. Assess for and report signs of adverse responses to medications including unstable vital signs, abnormal lab values, changes in mental status, changes in gait and fall risk. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: INSULIN-DEPENDENT DIABETES MELLITUS (IDDM)
Daily Nursing Skills: High risk for hyperglcemia related to inadequate endogenous insulin, prevent or minimize complications while establishing treatment regimen to control altered glucose metabolism, hypovolemia, hyperglycemia, sensory-perceptual alteration, complications of decreased tissue perfusion, cerebral dehydration, hypoxemia, acidosis. Diabetic foot care and inspection as diabetes can damage nerves and reduce blood flow to the feet. Complications may lead to amputation. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: INSULIN-DEPENDENT DIABETES RESIDENT UNABLE TO ADMINISTER OWN INSULIN
Daily Nursing Skills: High risk for hyperglycemia related to inadequate endogenous insulin, prevent or minimize complications while establishing treatment regimen to control altered glucose metabolism, hypovolemia, hyperglycemia, sensory-perceptual alteration, complications of decreased tissue perfusion, cerebral dehydration, hypoxemia, acidosis. Diabetic foot care and inspection as diabetes can damage nerves and reduce blood flow to the feet. Complications may lead to amputation. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: IV THERAPY
Daily Nursing Skills: Administration of IV therapy, inspection and care of IV site, observation for signs of phlebitis, infiltrate or infection at the site or systemic. Skilled monitor of condition for which the IV therapy was initiated to treat. Monitor signs for fluid overload, full vital signs and patient’s tolerance to therapy. Review of pertinent lab results. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. Daily
Utilize previous IV therapy guidelines plus:
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: JOINT REPLACEMENT: HIP/KNEE
Daily Nursing Skills: High risk for postoperative complications (hypovolemic shock, neurovascular damage, or thromboembolic phenomena) related to surgical trauma, bleeding, edema, improper positioning, or immobility. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: LEG ULCERATIONS
Daily nursing skills: Most leg ulcers result form chronic venous insufficiency, postthrombotic syndrome and/or severe varicose veins. Less commonly, they develop from arterial obstruction. Other causes include burns, trauma, and neurogenic disorders. There is a high risk for secondary bacterial infections of ulcerations. There is a high risk for delayed healing related to secondary infections, compromised circulation, and increased edema. Daily nursing skills include circulation monitoring, wound care, management of pain, management of secondary infections, and edema management. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: LIVER FAILURE
Daily Nursing Skills: High risk for hepatorenal failure, disseminated intravascular coagulation, bleeding esophageal varices. Encephalopathy from decreased nitrogen and glucose metabolism and cerebral blood flow, decreased oxygen saturation, and accumulation of nitrogen substances the liver cannot break down (restrict intake of protein). High risk for toxic accumulation of metabolic substances leading to kidney impairment. High risk for fevers and UTI’s, respiratory aspiration and pneumonia, spontaneous peritonitis, ascites from cardiovascular and pulmonary compromise. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Notes should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: LUNG CANCER (CHEMOTHERAPY)
Daily Nursing Skills: High risk for hypoxemia related to aberrant growth of lung tissue, bronchial obstruction, increased mucus production, or pleurisy. High risk for hemorrhage related to depression of platelet production by chemotherapy. High risk for pain associated with involvement of peripheral lung structures, metastasis, or chemotherapy. High risk for infection related to immunosuppression from chemotherapy and malnutrition. High risk for gastrointestinal complications related to chemotherapy: nausea, vomiting, and diarrhea with increased risk for fluid and electrolyte imbalance. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: MANAGEMENT AND DEVELOPMENT OF CARE PLAN
Daily Nursing Skills: The patient has many services, which do not require the direct skills of a nurse. But the management of the care plan for this patient requires the skills of a nurse. A person who is not a skilled nurse would not have the capability to understand the relationship among the services and their effect on each other. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: MULTIPLE SCLEROSIS Patient Name: ___________________________________________ Daily Nursing Skills: Multiple sclerosis or MS is a disease that affects the brain and spinal cord resulting in loss of muscle control, vision, balance, sensation (such as numbness) or thinking ability. With MS, the nerves of the brain and spinal cord are damaged by one's own immune system. Thus, the condition is called an autoimmune disease. Autoimmune diseases are those whereby the body's immune system, which normally targets and destroys substances foreign to the body such as bacteria, mistakenly attacks normal tissues. In MS, the immune system attacks the brain and spinal cord, the two components of the central nervous system. Other autoimmune diseases include lupus and rheumatoid arthritis. Assess and evaluate for Muscle weakness, Decreased coordination, Blurred or hazy vision, Eye pain and Double vision. As the disease progresses, symptoms may include muscle stiffness (spasticity), pain, difficulty controlling urination or difficulty thinking clearly. Late effects can be similar to patient’s who suffer brain injuries such as CVA’s with loss of skeletal muscle control and loss of independence with their activities of daily living. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
** As with any diagnosis, multi-system assessments are necessary to accurately encompass all aspects of the patient’s condition and response to treatment. Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: MYOCARDIAL INFARCTION
Daily Nursing Skills: High risk for cariogenic shock related to arrhythmias, impaired contractility or thrombosis, chest pain due to myocardial ischemia, hypoxemia due to ventilation-perfusion imbalance-minimize the risk of further infarction, optimize myocardial oxygen demand-supply ratio, high risk for activity intolerance related to myocardial ischemia, decreased contractility, arrhythmias. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: NEUROGENIC BLADDER/CATHETER IN PLACE
Daily Nursing Skills: The muscles and nerves of the urinary system work together to hold urine in the bladder and then release it at the appropriate time. Nerves carry messages from the bladder to the brain and from the brain to the muscles of the bladder telling them either to tighten or release. In a neurogenic bladder, the nerves that are supposed to carry these messages do not work properly. The following are possible causes of neurogenic bladder: diabetes, acute infections, accidents that cause trauma to the brain or spinal cord, genetic nerve problems, heavy metal poisoning. Assess and evaluate for urinary tract infection, kidney stones, chills, shivering, fever, urinary incontinence, small urine volume during voiding, urinary frequency and urgency, dribbling urine, loss of sensation of bladder fullness. The symptoms of neurogenic bladder may resemble other conditions and medical problems. An indwelling urethral (Foley) catheter is a closed sterile system that is inserted through the urethra to allow for bladder drainage. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: OBSERVATION, ASSESSMENT AND
Daily Nursing Skills: Observation and assessment are skilled services when the likelihood of change in a patient’s condition requires skilled nursing or skilled rehabilitation per personnel to identify and evaluate the patient’s need for possible modification of treatment or initiation of additional medical procedures until the patient’s treatment regimen is essentially stabilized. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PACEMAKER
Daily Nursing Skills: A pacemaker (or artificial pacemaker, so as not to be confused with the heart's natural pacemaker) is a medical device designed to regulate the beating of the heart. The purpose of an artificial pacemaker is to stimulate the heart when either the heart's native pacemaker is not fast enough or if there are blocks in the heart's electrical conduction system preventing the propagation of electrical impulses from the native pacemaker to the lower chambers of the heart, known as the ventricles. Assess and evaluate surgical wound, vitals are within parameters, activity tolerance, mobility, postural stability, cognitive changes, signs and symptoms of depression. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PAIN MANAGEMENT
Daily Nursing Skills: Skilled assessment of pain symptoms including duration, frequency, intensity, factors that exacerbate complaints of pain and factors that relieve pain symptoms. Impact pain has on mobility, mood, sleep, relationships with others. Response to pharmacology and non-pharmacological interventions. Inadequate pain control can contribute to insomnia, anxiety, depression and hostility. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Other comfort measures:
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PARKINSON’S DISEASE
Daily Nursing Skills: Parkinson's disease (also known as Parkinson disease or PD) is a degenerative disorder of the central nervous system that often impairs the sufferer's motor skills and speech. Parkinson's disease belongs to a group of conditions called movement disorders. The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia, normally caused by the insufficient formation and action of dopamine, which is produced in the dopaminergic neurons of the brain. PD is both chronic and progressive. PD is the most common cause of parkinsonism, a group of similar symptoms. PD is also called "primary parkinsonism" or "idiopathic PD" ("idiopathic" meaning of no known cause). While most forms of parkinsonism are idiopathic, there are some cases where the symptoms may result from toxicity, drugs, genetic mutation, head trauma, or other medical disorders. Assess for complications related to for muscle rigidity, dyphagia, drooling, sign and symptoms of aspiration, fatigue, tremor, postural instability, a slowing of physical movement (bradykinesia) and, in extreme cases, a loss of physical movement (akinesia). Assess and evaluate secondary symptoms including high level cognitive dysfunction and subtle language problems, disorders of mood, behavior, thinking, and sensation (non-motor symptoms). Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PELVIC OR LUMBAR FRACTURE
Daily Nursing Skills: A pelvic fracture is when one or more of the pelvic (hip) bones are broken. Your pelvis is made up of 5 bones, shaped in a circle. The 5 bones are the sacrum, coccyx (COX-iks), ilium, pubis, and ischium (ISH-e-um). Your pelvis protects and supports organs inside your body. Fracture of one or more parts of the spinal column (vertebrae) of the middle (thoracic) or lower (lumbar) back is a serious injury usually caused by high-energy trauma. People with osteoporosis, tumors or other underlying conditions that weaken bone can get a spinal fracture with minimal trauma or normal activities of daily living. The lumbar spine provides for both stability and support when humans ambulate. Assess and evaluate for signs and symptoms of DVT, immobility, instability, loss of balance, pain, posture, skin integrity, vitals, dizziness, dehydration, sensation, numbness, tingling. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PERMANENT PACEMAKER INSERTION
Daily Nursing Skills: High risk for arrhythmias related to pacemaker malfunctions or catheter displacement. High risk for infection related to surgical disruption of skin barrier. High risk for bleeding, infection (elevated WBC), drainage at insertion site. High risk for vagal-medicate arrhythmias. Observations and assessment for deviation from baseline vital signs which may indicate pacemaker failure of complications. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PNEUMONIA
Daily Nursing Skills: High risk for hypoxemia related to inflammatory response to pathogen and inadequate airway and alveolar clearance, symptoms related to pain fever and pleuritic irritation, activity tolerance from increased oxygen demands and a compromised respiratory system. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
CORE COMPONENTS DIAGNOSIS: PSYCHIATRIC DISORDERS
Daily Nursing Skills: High risk for exacerbation of symptoms in mood or behaviors that may negatively impact self or others. Medication management and skilled monitoring of effects. Management in care plan to promote stability of condition. Behavior plans, interventions and need for modification. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. DAILY NURSES NOTE should address one or more of these areas of skilled nursing.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: PULMONARY DISEASE
Daily Nursing Skills: High risk for hypoxemia related to inadequate gas exchange. High risk for respiratory infection secondary to limited ability to expand lungs secondary to disease effects. High risk for anxiety and depression. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: RADIATION THERAPY OR CHEMOTHERAPY
Daily Nursing Skills: Chemotherapy refers to drugs that are used to kill microorganisms (bacteria, viruses, fungi) and cancer cells. Most commonly, the term is used to refer to cancer-fighting drugs. Cancer chemotherapy kills or arrests the growth of cancer cells by targeting specific parts of the cell growth cycle. However, normal healthy cells share some of these pathways, and thus are also injured or killed by chemotherapy. This is what causes most side effects from chemotherapy. A patient becomes less resistant to any type of virus of infection putting them at risk for more acute complications. Radiation therapy is a treatment approach that uses radiation to destroy cancer cells. Radiation therapy is used to fight many types of cancer. Often it is used to shrink the tumor as much as possible before surgery to remove the cancer. Radiation can also be given after surgery to prevent the cancer from coming back. For certain types of cancer, radiation may be the only treatment needed. Radiation treatment may also be used to provide temporary relief of symptoms, or to treat malignancies (cancers) that cannot be removed with surgery. Radiation therapy can have many side effects. These side effects depend on the part of the body being irradiated and the dose and schedule of the radiation:
Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: REHAB FOR STRENGTHENING DUE TO FUNCTIONAL LOSS
Daily Nursing Skills: There are multiple health benefits that are derived from endurance training and/or strengthening in the elderly. For example, bone density, insulin sensitivity, and co-morbidities associated with obesity can be effectively managed with resistance exercise when it is conducted on a regular basis. Assess and evaluate signs and symptoms of exacerbation of primary and secondary medical diagnosis related to complications of functional loss and post therapy intervention. Often patients participate with 100% effort in the therapy appointment as they view this as the portal to returning home. Following return to the nursing unit a patient can experience a decline in medical status due to the efforts exerted during a rehabilitation session. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: RENAL FAILURE WITH DIALYSIS Patient Name: ___________________________________________ Daily Nursing Skills: High risk for hyperkalemia, related to decreases renal excretion, metabolic acidosis, excessive dietary intake, blood transfusion, catabolism, and noncompliance with therapeutic regimen. High risk for pericarditis, pericardial effusion, and pericardial tamponade related to uremia or inadequate dialysis. High risk for hypertension related to sodium and water retention and malfunction of the renin-angiotensin-aldosterone system. High risk for anemia related to decreased life span of RBC’s and blood loss during hemodialysis. High risk for osteodystrophy and metastatic calcification related to hyperphosphatemia, hypocalcemia, abnormal vitamin D metabolism, hyperparathyroidism, and elevated aluminum levels. High risk for nutritional deficit related to anorexia, nausea, vomiting, diarrhea, restricted dietary intake, GL inflammation with poor absorption, and altered metabolism of proteins, lipids and carbohydrates. High risk for altered oral mucous membrane and unpleasant taste related to accumulation of urea and ammonia. High risk for impaired skin integrity related to decreased activity of oil and sweat glands, scratching, capillary fragility, abnormal blood clotting, anemia, retention of pigments, and calcium deposits on the skin. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: RHEUMATOID ARTHRITIS Patient Name: ___________________________________________ Daily nursing skills: High risk for joint deformity, pain and muscle atrophy. Risk to other body systems as rheumatoid nodules may for in the heart, lungs, and spleen. Manifestations of the multi-system involvement include: Pleuritis, Pulmonary Fibrosis, Pericarditis, Aortic Valve Disease, Lymphadenopathy, Glaucoma, and Spleomegaly. The acute narcotizing vacillates that is common in the autoimmune disorders may result in myocardial infarction, cerebrovascular accident, Kidney damage, and Raynaud’s disease. High risk for ineffective pain control, fatigue, negative self-concept, decreased mobility and injuries with the risk for development of skin ulcers and contractures. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS
Daily Nursing Skills: High risk for trauma related to seizure activity. High risk for aspiration secondary to decreased consciousness following a seizure. High risk for impaired adjustment related to disability requiring change in lifestyle and possible change in independence. High risk for adverse effects of non-therapeutic drug levels. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. Observation of any seizure activity – petit mal or grand mal seizure. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: SKELETAL TRACTION
Daily Nursing Skills: Patient is at high risk for skin breakdown or dermatitis under skin traction, complications of immobilization; stasis pneumonia, thrombophlebitis, pressure ulcers, urinary tract infection, calculi, constipation. Altered tissue perfusion, deformity related to traction therapy and underlying pathology. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: SPECIALTY BED
Daily Nursing Skills: High risk for complications related to the reason the specialty bed is necessary. Local and systemic infection including high risk for osteomyelitis. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: SPEECH AND LANGUAGE PROBLEMS (APHASIA)
Daily Nursing Skills: Aphasia usually results from damage to the left side of the brain, which is the area responsible for language. Some people who have aphasia may not be able to understand written or spoken language, read or write, or express their own thoughts. Recovering from significant injury to the brain may take from days to years. Much of your improvement in motor functioning-walking, using your arms and legs-comes in the early phase of stroke recovery. Provide detailed assessment documentation to support the patient’s functional improvements and deteriorations on a daily basis. Assess and evaluate vitals, oral communication, safety, ability to make daily needs known, signs and symptoms of distress, and signs and symptoms of neurovascular episodes. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
** As with any diagnosis, multi-system assessments are necessary to accurately encompass all aspects of the patient’s condition and response to treatment. Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: SUCTIONING
Daily Nursing Skills: There are many clinical reasons when suctioning (the removal of unwanted secretions from the respiratory tract) is necessary. For instance, patient’s with chronic lung diseases, respiratory infections (pneumonia, bronchitis) and paralysis require the skills of a clinical professional to at times assist the patient with the removal of such secretions. Suctioning can be performed through the oral route, nasopharyngeal route, or by tracheal aspiration. Medicare recognizes the latter two routes as requiring the skills of a licensed professional to be considered a covered service. Many facilities have policies surrounding the performance of suctioning at the bedside and should include strategies to move secretions through peripheral airways. These measures include: appropriate hydration and adequate humidification of inspired gases (to keep secretions thin); coughing and deep breathing; frequent position changes (may need rotation bed); chest physiotherapy; and bronchodilating agents as ordered. Above all, the ongoing skilled observation and assessment are vital to the task of effective suctioning. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TEACHING AND TRAINING
Daily nursing skills: High risk for complications related to knowledge deficit for self-care and management of disease process, treatment or conditions. Patient requires teaching and training in the specified area to promote medical recovery, stability and prevention of exacerbation of symptoms and or conditions. Patient requires daily skilled nursing for evaluation of outcomes of teaching and training interventions. There is a high likelihood for the need to modify the teaching and training program to attain the desired outcome. The daily skills of a nurse are required to assess the effectiveness of the teaching and training program.
Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TERMINAL CARE
Daily Nursing Skills: At risk for powerlessness related to the inevitability of death. Lack of control over bodily functions, dependence on others for care. At risk for spiritual distress, identity disturbance. High risk for pain related to underlying disease or injury (see specific disease related Guideline). High risk for fluid, volume deficit related to anorexia and dehydration related to imminent death. High risk related to multi-organ failure with end of life disease processes. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TOTAL HIP REPLACEMENT
Daily Nursing Skills: Patient is at high risk of complications related to surgical procedure, infection. thrombophlebitis, pulmonary embolism, compartment syndrome, unusual bleeding related to anticoagulation therapy, neurovascular complications. Patient is at risk for complications related to decreased physical mobility including pressure ulcers, constipation, and urinary tract infection. Patient is at risk for surgical wound infection and delayed healing of wound. Patient is at risk for dislocation of prosthesis secondary to knowledge deficit or cognitive deficits with total hip precautions. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TOTAL PARENTERAL NUTRITION (TPN) Patient Name: ___________________________________________ Daily Nursing Skills: High risk for sepsis, mechanical injury from catheter, pneumothorax, hemothorax, arterial puncture, air emboli, catheter emboli, catheter and venous thrombosis. Metabolic disorders, hypoglycemia, fluid and electrolyte abnormalities, hyperglycemia, essential fatty deficiency. Neurological abnormalities. High risk for fluid volume excess, or deficit. High risk for nutrition deficit. High risk for infection related to invasive CVC, leukopenia, or damp dressing. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TRACHEOSTOMY
Daily Nursing Skills: A tracheostomy is an opening surgically created through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway, and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.Rubbing of the trach tube and secretions can irritate the skin around the stoma. Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties. Care should be done at least once a day; more often if needed. People with new trachs or who are on ventilators may need trach care more often. Tracheostomy dressings are used if there is drainage from the tracheostomy site or irritation from the tube rubbing on the skin.Some older children and teens have trach tubes with an inner cannula. Some inner cannulas are disposable (DIC: Disposable Inner Cannula). These should be changed daily, discarding the old cannula. Check with your equipment vendor regarding disposable cannulas. For the reusable cannulas, the cannula should be cleaned 1 to 3 times a day and more often if needed. Do not leave the inner cannula out for more than 15 minutes. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: TRACTION
Daily Nursing Skills: Traction uses weights and pulleys to put tension on a displaced bone or joint, such as a dislocated hip, to realign the bone and immobilize it. Traction is also used to keep a group of muscles stretched (such as the lower spinal muscles) to reduce muscle spasm. As a treatment, traction will involve a certain amount of tension to pull the body part into another position, a length of time to use the tension, and a way to maintain the tension. Traction is most often used as a temporary measure when operative fixation is not available for a period of time. Traction can either be applied through the skin (skin traction) or through pins inserted into bones (skeletal traction). Skin traction is generally less desirable due to the fact that skin can be injured when pressure is applied for extend periods of time. Skin traction called Buck's traction is commonly used in patients who have a hip fracture. Skeletal traction does have the disadvantage of complications associated with pin insertion, and infections can come from the sites of pin insertion. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: URINARY RETENTION
Daily nursing skills: High risk for kidney damage and electrolyte imbalance related to inability to empty bladder. High risk for infection secondary to invasive procedures, catheters- indwelling or intermittent, and stasis of urine in the bladder promoting growth of microbes. Skilled assessments and evaluation of signs of bladder distention and evaluation of intake and output measurements. Skilled assessment of symptoms and conditions precipitating urinary retention. Evaluation of laboratory data, neurological assessment and medication effects with voiding pattern. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSING NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: URINARY TRACT INFECTION
Daily Nursing Skills: High risk for sepsis related exacerbation of symptoms. High risk for recurrent UTI, observation for S&S of recurrence, monitoring of labs, effectiveness of medication, effects of inactivity, decreased nutrition on mobility and endurance. Following nursing admission assessment, identify which of the list areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly Note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: VENTILATOR
Daily Nursing Skills: A medical ventilator is a device designed to provide mechanical ventilation to a patient. In its simplest form, a ventilator consists of a compressible air reservoir, air and oxygen supplies, a set of valves and tubes, and a disposable or reusable "patient circuit". The air reservoir is pneumatically compressed several times a minute to deliver room-air, or in most cases, an air/oxygen mixture to the patient. When overpressure is released, the patient will exhale passively due to the lungs' elasticity, the exhaled air being released usually through a one-way valve within the patient circuit. The oxygen content of the inspired gas can be set from 21 percent (ambient air) to 100 percent (pure oxygen). Pressure and flow characteristics can be set mechanically or electronically. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these assessment results as evidence of ongoing skilled observation, assessment and ongoing care planning for the individual patient. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes, which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care.
Remove from Chart Weekly CORE COMPONENTS DIAGNOSIS: WOUND/DRESSING CHANGES
Daily Nursing Skills: High risk for infection or delayed healing related to impaired skin integrity. High risk for pain related to trauma procedure. Following nursing admission assessment, identify which of the listed areas are pertinent for each patient. DAILY NURSES NOTES should address one or more of these areas of skilled nursing. A comprehensive Weekly note should include all of the identified nursing skills, plus any periodic episodes which have occurred. This list should be kept updated, eliminate or add skills as appropriate for the patient’s plan of care. Daily
Weekly
Remove from Chart Weekly MEDICARE PART B NOTES When a long-term care resident has a change of condition (improvement or decline), nursing drives the therapy intervention process. It is imperative that the resident’s functional status is documented in a shift note identifying the change which facilitated the referral to therapies for a screen and potential initiation of a skilled program. Harmony recommends that nursing observe the patient when a decline or improvement is identified and document on the specific behaviors which are outside of the norm for the particular patient. Harmony supports documentation by nursing or other department of three episodes of functional performance or other area of concern prior to the initiation of therapy. The exception to this suggestion would be the patient who is experiencing difficulty swallowing, choking or aspirating, which should be addressed immediately to ensure that the status change is not self-limiting. The initial date of the change (i.e., first of three notes) is the onset date which should be used on the therapy evaluation Forms 700 and 701 (when those forms are being utilized). Long term residents should be screened on a routine basis (annually at a minimum) by Rehab however; there are other times when patients will be identified by caretaker staff which contributes to improving the quality of care to residents.
PART B NOTES |
Which instructions would the nurse include for a patient who will be using an expectorant
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