Archive for the ‘nursing assistant’ tag
Nursing tips: Recording/documenting basic details of in-patients
One of the essential duties of a nurse, or a certified nursing assistant, in the hospital ward is to properly assess, collect and record details of a patient admitted for treatment, and also properly document the same for reference by other nurses as well as the doctors attending the patient. A nurse should maintain the details in a proper manner such that it will become part of medical history of the patient and will be a guide for treating the patient.
As soon as the patient is admitted for in-hospital treatment to his or her physical illness and allocated a room or a bed in the ward, it is the responsibility of the nurse in charge of the ward at that time to collect and record the basic details about the patient apart from the name, age and the nature of illness.
The nurse should assess the conscious level of the patient when admitted for treatment. The nurse should also assess the mood or the comfort level of the patient at the time of admission. These can be gauged from the way the patient presents himself or herself. If in doubt, it is advisable to get it confirmed and documented.
The CNA should next look for the vital signs as well as tissue perfusions and make a note of the conditions of the same. Enquire the patient’s bowel and urinary movements and also enquire whether the patient has any problem in moving freely around without any assistance. If he or she has some problems in free movement, then the entire body needs to be inspected to find out the pressure areas that might be the cause for pain.
The nurse should also make note of the appetite of the patient as well as acceptability of the food provided in the hospital for the patient.
