Unit 6 - Documentation

Question 1

Documentation, whether written or electronic, should be:

FA Cx4

Answer 1

Factual
- words such as “appears” or “seems” usually precede a judgment and therefore are not acceptable

Accurate
- measurements, don’t use abbrevs.; date/sign all entries with name and designation; if late, write current date and time must be written and “late entry”

Complete
- see next card

Current
- written in timely fashion

Chronological
- describe observations, document actions

Compliant with applicable standards set out by regulatory bodies
- don’t erase/whiteout, black ink, don’t pre-chart, protect password

Question 2

Complete assessment documentation will include: (4)

CACO

Answer 2

Complete health hx

Ax findings

• description of any foot pathologies
• ID risk factors for foot complications

Care plan based on the client’s needs, including:
o goals for tx
o client education
o referrals

Ongoing evaluation and modification of the care plan

Question 3

After the assessment data is collected the foot care nurse can begin to develop a plan of care.

After analyzing the data the nurse has a better understanding of the client’s needs.

What are the next 3 steps?

Answer 3

use client input (gathered in ax process) to individualize plan

cluster data logically

generate nursing diagnoses

Question 4

4 categories

Answer 4

Diagnosis - problem and etiology
Goals - SMART
Interventions
Evaluation

Question 5

Common nursing diagnoses that may be applied to the lower limb include but are not limited to:

PII SHIR

piishir

Answer 5

pain
impaired skin integrity
impaired tissue profusion

self-care deficit
health seeking behaviour
ineffective health maintenance
risk factors for foot complications

Question 6

When establishing a plan of care, and setting goals, the nurse should remember to:

(Memorize, like, 5)

Answer 6

forewarn the patient about procedures or interventions

teach skills to the patient

assist the decision-making process by offering choices

involve the family (provided confidentiality is not at issue)

reinforce appropriate behaviours

explain procedures and concepts in familiar and easily understood terms

discuss the plan of care, and do not dictate

advise the patient regarding the care plan and options

be willing to change or modify planned goals as the situation dictates.

Question 7

The adult learner is characterized by:

Answer 7

Self-directed approach to learning
- choosing when/what/how to learn

Life experienced learning
- drawing on past experience to build new skills)

Social motivation
- a father may be motivated to improve his health for the sake of his children

Application of learned behaviours in an expedient manner
- short term goals are usually more effective when an opportunity to practice learned skills is given

Question 8

After an assessment, the nurse will accurately document the findings.

The nurse then…?

Answer 8

shares observations with the client

Question 9

After an assessment, the nurse will accurately document the findings.

The nurse then shares observations with the client and…?

Answer 9

together they devise a plan of care

Question 10

With the client’s input throughout the assessment process is important to generating a care plan, because why?

Answer 10

the care plan will be individualized and focused on the areas the client deems as most important

Question 11

SMART goals

Answer 11

Specific
Measurable
Achievable
Realistic
Timely

Question 12

Example of diagnosis and goals

Answer 12

Patient is unable to care for his/her own feet
Etiology
Related to:
poor vision
weakness of hands
lack of coordination
inability to reach feet
decreased mental alertness

Question 13

Documentation provides…?

Answer 13

proof of the quality care that the foot care nurse has provided to the client

Question 14

What should be documented?

Answer 14

Interventions
Client’s response
Plan

Question 15

When should documentation occur?

Answer 15

directly after the foot care is provided

Question 16

For the purposes of documentation, basic foot care is?

Answer 16

care that takes less than 35 minutes to complete

Question 17

For the purposes of documentation, basic foot care is care that takes less than 35 minutes to complete. It consists of:

(

Answer 17

swabbing and cleansing the nails

cleaning and defining the nail edge

trimming the nails following the natural curve of the nail

filing rough edges until smooth

cleaning away loose detritus

filing and smoothing corns/calluses

applying emollients

client education

care plan

Question 18

Extensive foot care is care that takes longer than 35 minutes to complete. It consists of…?

Answer 18

Everything included in basic foot care PLUS

work on problem nails
o ingrown nails
o fungal nails
o thickened horny nails
o poor quality nails r/t structural deformities

work on corns/calluses

Question 19

What is a consultation?

Answer 19

when one health care professional formally seeks the advice of another health care professional

Question 20

How can consultations occur?

Answer 20

A consultation can occur face to face, over the phone or through confidential email.

For example, a new foot care nurse may consult with an experienced foot care nurse when presented with extreme Ram’s Horn nails for the first time.

Question 21

What is a referral?

Answer 21

an arrangement that is made to have a client receive services by another member of the foot health care team.

Question 22

How does the nurse make a referral?

Answer 22

advise or assist the client to set up a visit with their family physician for further assessment and treatment

An example of a referral would be if a foot care nurse is performing care on a client with diabetes and observes a new open area on the foot.

Question 23

What should accompany a referred client?

Answer 23

A written referral

Question 24

What would the foot care nurse document in a written referral?

Answer 24

brief and concise background info
(name, age, history r/t reason for referral)

pertinent assessment information

current nursing interventions or treatments

foot care nurse’s full name, signature and contact information

Question 25

Both consultations and referrals must be…?

Answer 25

documented in the client’s chart

Question 26

Guidelines for Writing a Complete Nursing Care Plan

3 re. the NCP
Include (1)
Headings
Dates (2)
Each visit (2)

Answer 26

the NCP should be individualized to suit the client

the NCP can be standardized and preprinted as long as they can be individualized to suit the client

the NCP should be organized and clear.
Any foot care nurse should be able to read the plan and quickly understand what the client’s needs are

Include collaborative interventions such as referrals to other members of the foot health care team

use headings such as: Nursing Diagnosis, Goals/Outcomes, Interventions, Evaluation

evaluation dates must be clearly written

all NCP must be dated and signed

NCP must be referred to and updated at each visit

Question 27

Nursing Dx

Answer 27

Grooming Self Care Deficit r/t decreased visual acuity & musculoskeletal impairment of hands AEB client statement “I can’t see my toenails to cut them” & limited strength and ROM in both hands

Question 28

Goals/Outcomes

Answer 28

The client’s feet will be groomed regularly AEB trimmed toenails and reduced calluses

by October 14, 2008.

Signature & today’s date

Question 29

Intervx

Answer 29

1. Foot care nurse to visit q 6 weeks
2. Assess the client’s ability for self care
3. Assess lower limb and feet
4. Trim toenails
5. Reduce calluses
6. Refer to pedorthist for foot wear to off load pressure