 State the purpose of a
resident comprehensive
assessment
 State the purpose of a
resident care plan
 State the purpose...
 Identifies specific
therapeutic actions for
resident based on their
individualized need
 STNA should attend care
confer...
 Resident care problems
and strengths to be
addressed by the health
care team are identified
and ways to help the
residen...
 A member of the care
team.
 Provides/gathers data
and information that will
be helpful for the
assessment and care
plan...
 Vital Signs
› Temperature, Pulse,
Respirations
 Skin Care
› Bathing, Turning &
Positioning
 Elimination
› Urine, Bowel...
 Identify the purpose of a
medical record
 Identify ways the NA can
contribute to the medical
record
 Identify common m...
 Chronological record of
the resident’s condition
and care.
 Legal record of medical
and nursing care.
 Way for the hea...
 Observing the resident
 Reporting changes to
the nurse in charge
 Recording information
according to facility
policy.
...
 Always remember – if it is
not documented, it was
not done.
 Use ink
 Legible & neat
 Agency-approved
abbreviations
 Correct spelling,
punctuation & grammar
 No erasing or white...
 Military Time
 Never skip lines
 No spaces between
entry and signature
 Fill in empty space with a
line
 Record what you did
and/or ...
 I & O Sheets
 Meal Records
 Restorative Records
 Vital Sign Sheets &
Graphic Records
 ADL Records
 Bowel & Bladder
...
 Do your friends tell you
that you notice EVERTHING
– or maybe NOTHING?
 Observation is critical in
your role as a nursi...
 Are there cars parked on
the sides of the road?
 What color is the pickup
truck driving in the road?
 Any minivans aro...
 How many cars did you
see?
 How many trucks?
 How many of the
vehicles in the parking
lot can you describe?
 How many vehicles where
in the intersection?
 Across the street, are there
any vehicles parked on
the side?
 Can you d...
 Your observations can
alert you to changes in
the resident’s condition
 Observations should be
made continuously
during...
 SEE
› What might we see?
 FEEL
› What might we feel?
 HEAR
› What might we hear?
 SMELL
› What might we smell?
 What is the resident’s
general appearance?
 Is the resident alert,
confused, drowsy?
 What is their activity level?
 ...
 Objective: Signs
› Observed through the 5
senses: seen, felt, heard,
smelled or tasted
 Subjective: Symptoms
› Things t...
 Breathing is labored
(difficult)
› Objective
 Chest pain
› Subjective
 Pulse
› Objective
 Dark urine
› Objective
 Na...
 Changes in the
resident’s condition are
reported to the nurse
immediately.
 Observations are
reported and recorded
exac...
 Identify basic emotional needs
of the residents in a LTCF
 Identify actions the STNA can
take to meet the emotional
nee...
 Human Psychologist
 Believed that individuals
are controlled by their
values and the choices
they make
 Model of human...
 Physiological Needs
› Survival
 Food
 Water
 Air
 Sleep
 Sex
Physiological Needs
 Safety
› Security, stability, keeping
us from harm
 Physical Security
 Shelter
 Safe environment
Physiological Needs
...
 Love/Belonging
› Need to give and receive
love and affection
 Friendship
 Family
 Sexual intimacy
Physiological Needs...
 Esteem
 Confidence
 Content
 Respect self and others’
respect
 Prestige & Power
Physiological Needs
Safety
Love/Belo...
Physiological Needs
Safety
Love/Belonging
Esteem
Self
Actualization
Become what we
are capable of
becoming
Independence
 Promote by
› Encouraging self care
› Encouraging decision
making
 Clothing
 Food
 Activities
Supportive Environment
 Promote by
› Physical Environment
 Proper medical and
dental care
 Safe, comfortable clothing
...
Social Interaction
 Promote by
› Encouraging contact with
other residents
› Encouraging contact with
family and friends o...
Recognition as an
Individual
 Promote by
› Be respectful
› Allow for privacy
› Encouraging self
expression through crafts...
Self Actualization
 Promote by
› Respect beliefs – don’t
impose yours
› Learn needs and
preferences that assist
› Encoura...
 Anger
 Demanding
 Self-centered
 Aggressive
 Withdrawl
 Inappropriate sexual
behavior
 Acknowledge frustration or
frightening situations
 Treat with dignity and
respect
 Answer questions clearly
and thorou...
Natcep day 4
Natcep day 4
Natcep day 4
Natcep day 4
Natcep day 4
Natcep day 4
Natcep day 4
Natcep day 4
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Natcep day 4

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Natcep day 4

  1. 1.  State the purpose of a resident comprehensive assessment  State the purpose of a resident care plan  State the purpose of the resident care conference  Identify the role of the STNA in the care planning conference  Describe the STNA’s role in gathering and documenting information
  2. 2.  Identifies specific therapeutic actions for resident based on their individualized need  STNA should attend care conferences at periodic intervals to gain insight into caring for residents with emotional needs
  3. 3.  Resident care problems and strengths to be addressed by the health care team are identified and ways to help the resident are identified.  Resident care plans are communicated to all 3 shifts and to all staff involved in the resident’s care to ensure consistency.
  4. 4.  A member of the care team.  Provides/gathers data and information that will be helpful for the assessment and care planning process.
  5. 5.  Vital Signs › Temperature, Pulse, Respirations  Skin Care › Bathing, Turning & Positioning  Elimination › Urine, Bowel Movements  Ambulation › Walking, devices to help walking  Mobility › Independent? › Staff Assistance?
  6. 6.  Identify the purpose of a medical record  Identify ways the NA can contribute to the medical record  Identify common medical abbreviations  Identify the proper methods of documentation
  7. 7.  Chronological record of the resident’s condition and care.  Legal record of medical and nursing care.  Way for the health care team to communicate information about the person.  Can be used as court evidence of a person’s problems, treatment and care.
  8. 8.  Observing the resident  Reporting changes to the nurse in charge  Recording information according to facility policy.  Participating in care conferences.
  9. 9.  Always remember – if it is not documented, it was not done.
  10. 10.  Use ink  Legible & neat  Agency-approved abbreviations  Correct spelling, punctuation & grammar  No erasing or white out  Agency policy for error correction  Sign with first initial, last name, and title
  11. 11.  Military Time
  12. 12.  Never skip lines  No spaces between entry and signature  Fill in empty space with a line  Record what you did and/or saw  Chronological order  Use direct quotes from resident with quotation marks  Record safety measures  Correct chart
  13. 13.  I & O Sheets  Meal Records  Restorative Records  Vital Sign Sheets & Graphic Records  ADL Records  Bowel & Bladder Program Records  Examples in Chapter 6 beginning on page 66
  14. 14.  Do your friends tell you that you notice EVERTHING – or maybe NOTHING?  Observation is critical in your role as a nursing assistant  Key objectives: › Discuss the importance of observation › Describe various observation techniques › Identify observations to be made during resident care › Demonstrate how to report and record observations
  15. 15.  Are there cars parked on the sides of the road?  What color is the pickup truck driving in the road?  Any minivans around?  What does the blue sign say?  What’s the speed limit?  Are there any pedestrians on the road?
  16. 16.  How many cars did you see?  How many trucks?  How many of the vehicles in the parking lot can you describe?
  17. 17.  How many vehicles where in the intersection?  Across the street, are there any vehicles parked on the side?  Can you describe at least one of the vehicles driving through the intersection?  Are there any potential witnesses? › If so, what was the witness doing? › If so, where was he or she?  What was the speed limit?  Was there anyone parked in the first parking spot?
  18. 18.  Your observations can alert you to changes in the resident’s condition  Observations should be made continuously during resident care  BE ALERT at ALL TIMES
  19. 19.  SEE › What might we see?  FEEL › What might we feel?  HEAR › What might we hear?  SMELL › What might we smell?
  20. 20.  What is the resident’s general appearance?  Is the resident alert, confused, drowsy?  What is their activity level?  What is the color of his/her skin, mouth, fingernails?  What is the condition of his/her breathing?  How does the resident manage eating, drinking, elimination?  Has there been a change in his/her sleeping habits?  What is his/her mood or behavior?
  21. 21.  Objective: Signs › Observed through the 5 senses: seen, felt, heard, smelled or tasted  Subjective: Symptoms › Things the resident tells you that you cannot observe through the senses
  22. 22.  Breathing is labored (difficult) › Objective  Chest pain › Subjective  Pulse › Objective  Dark urine › Objective  Nausea › Subjective  Sweating › Objective  Breath is “fruity” › Objective  Fearful › Subjective
  23. 23.  Changes in the resident’s condition are reported to the nurse immediately.  Observations are reported and recorded exactly as seen, felt, heard or smelled, or in the resident’s own words.
  24. 24.  Identify basic emotional needs of the residents in a LTCF  Identify actions the STNA can take to meet the emotional needs of the resident  Recognize common behaviors displayed when emotional needs are not met  Describe therapeutic interventions the STNA may use in response to a resident’s behavior  Describe the role of the care plan and care conference in responding to a resident’s behavior
  25. 25.  Human Psychologist  Believed that individuals are controlled by their values and the choices they make  Model of human needs › Hierarchy of Needs
  26. 26.  Physiological Needs › Survival  Food  Water  Air  Sleep  Sex Physiological Needs
  27. 27.  Safety › Security, stability, keeping us from harm  Physical Security  Shelter  Safe environment Physiological Needs Safety
  28. 28.  Love/Belonging › Need to give and receive love and affection  Friendship  Family  Sexual intimacy Physiological Needs Safety Love/Belonging
  29. 29.  Esteem  Confidence  Content  Respect self and others’ respect  Prestige & Power Physiological Needs Safety Love/Belonging Esteem
  30. 30. Physiological Needs Safety Love/Belonging Esteem Self Actualization Become what we are capable of becoming
  31. 31. Independence  Promote by › Encouraging self care › Encouraging decision making  Clothing  Food  Activities
  32. 32. Supportive Environment  Promote by › Physical Environment  Proper medical and dental care  Safe, comfortable clothing  Rooms and halls clutter free  Protection from others (and self, if needed) › Emotional Environment  Treat with respect, acceptance and patience  Supportive of family
  33. 33. Social Interaction  Promote by › Encouraging contact with other residents › Encouraging contact with family and friends outside the LTCF
  34. 34. Recognition as an Individual  Promote by › Be respectful › Allow for privacy › Encouraging self expression through crafts, reminiscing and recognizing past accomplishments
  35. 35. Self Actualization  Promote by › Respect beliefs – don’t impose yours › Learn needs and preferences that assist › Encouraging activities that promote self actualization
  36. 36.  Anger  Demanding  Self-centered  Aggressive  Withdrawl  Inappropriate sexual behavior
  37. 37.  Acknowledge frustration or frightening situations  Treat with dignity and respect  Answer questions clearly and thoroughly  Keep them informed  Do not keep them waiting  Explain reasons for long waits  Stay calm and professional  Do not argue  Listen – use silence  Protect yourself from violent behaviors  Report inappropriate behavior to the nurse

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