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Page 1: Natcep day 4

NATCEP Day FourResident Comprehensive

Assessment, Care Plan and Conference

Page 2: Natcep day 4

OB

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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

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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

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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.

 

Page 5: Natcep day 4

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A member of the care team.

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

Page 6: Natcep day 4

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INFO

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Vital Signs› Temperature, Pulse,

Respirations Skin Care

› Bathing, Turning & Positioning

Elimination› Urine, Bowel Movements

Ambulation› Walking, devices to help

walking Mobility

› Independent?› Staff Assistance?

Page 7: Natcep day 4

NATCEP Day FourMedical Record

Page 8: Natcep day 4

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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

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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.

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Observing the resident Reporting changes to

the nurse in charge Recording information

according to facility policy.

Participating in care conferences.

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

Page 12: Natcep day 4

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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

Page 13: Natcep day 4

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Military Time

Page 14: Natcep day 4

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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

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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

Page 16: Natcep day 4

NATCEP Day FourObservational Skills

Page 17: Natcep day 4

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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

Page 18: Natcep day 4

LET’S

FIN

D O

UT. . . .

Page 19: Natcep day 4

WH

AT D

ID Y

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SEE?

Are there cars parked on the sides of the road?

What color is the pickup truck driving in the road?

Any minivans around? What does the blue sign

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

pedestrians on the road?

Page 20: Natcep day 4

WA

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AG

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?

Page 21: Natcep day 4

WH

AT D

ID Y

OU

SEE?

How many cars did you see?

How many trucks? How many of the

vehicles in the parking lot can you describe?

Page 22: Natcep day 4

LA

ST O

NE. . . . .

Page 23: Natcep day 4

WH

AT D

ID Y

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SEE?

How many vehicles where in the intersection?

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

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

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

doing?› If so, where was he or she?

What was the speed limit? Was there anyone parked in

the first parking spot?

Page 24: Natcep day 4

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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

Page 25: Natcep day 4

WAY

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SEE› What might we see?

FEEL› What might we feel?

HEAR› What might we hear?

SMELL› What might we smell?

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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?

Page 27: Natcep day 4

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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

Page 28: Natcep day 4

WH

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Breathing is labored (difficult)› Objective

Chest pain› Subjective

Pulse › Objective

Dark urine› Objective

Nausea› Subjective

Sweating› Objective

Breath is “fruity”› Objective

Fearful› Subjective

Page 29: Natcep day 4

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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.

Page 30: Natcep day 4

NATCEP Day FourMeeting the Basic Emotional

Needs of Residents

Page 31: Natcep day 4

OB

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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

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Human Psychologist Believed that

individuals are controlled by their values and the choices they make

Model of human needs› Hierarchy of Needs

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Physiological Needs› Survival

Food Water Air Sleep Sex

Physiological Needs

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Safety› Security, stability,

keeping us from harm Physical Security Shelter Safe environment

Physiological Needs

Safety

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Love/Belonging› Need to give and receive

love and affection Friendship Family Sexual intimacy

Physiological Needs

Safety

Love/Belonging

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HIE

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Esteem Confidence Content Respect self and others’

respect Prestige & Power

Physiological Needs

Safety

Love/Belonging

Esteem

Page 37: Natcep day 4

HIE

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Physiological Needs

Safety

Love/Belonging

Esteem

Self ActualizationBecome what we are capable of becoming

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Page 39: Natcep day 4

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Independence Promote by

› Encouraging self care› Encouraging decision

making Clothing Food Activities

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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

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Social Interaction Promote by

› Encouraging contact with other residents

› Encouraging contact with family and friends outside the LTCF

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Recognition as an Individual

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

expression through crafts, reminiscing and recognizing past accomplishments

Page 43: Natcep day 4

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Self Actualization Promote by

› Respect beliefs – don’t impose yours

› Learn needs and preferences that assist

› Encouraging activities that promote self actualization

Page 44: Natcep day 4

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Anger Demanding Self-centered Aggressive Withdrawl Inappropriate sexual

behavior

Page 45: Natcep day 4

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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