Course Intro: Nursing Rules, Medical Reporting & Recording
Basic Rules of Conduct
- Respect other people as individuals.
- Follow instruction of your charge nurse to the best of your ability.
- Do NOT perform tasks that are not within your legal limits.
- Do NOT perform any tasks you are not prepared to do.
- Protect the person’s privacy at all times.
- Keep information regarding patient confidential at all times.
- When assisting patients, keep them covered at all times.
- If a visitor is in the room, kindly ask them to step out.
- Never open patients mail.
- Never discuss the patients care with other team members, family, or anyone except the charge nurse.
- Always allow the patient privacy when asked.
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The Never Never Rules:
Examples of abuse are and is note limited to unclean or unsafe living conditions, significant weight loss, missing equipment, medication not properly administered, pressure ulcers (Bed Sores). If you do notice any of these signs notify the nurse. If these things go un-looked you could be held legally responsible.
Patient Rights and legal issues:
Never except any money or any items as gratitude (Tips or thank you presents) from the patient. Explain to them that you appreciate the thought but you legally can’t take it.
Professional Sexual Misconduct
Never touch a patient in a sexual manner even if the patient consents never conduct sexual activity. If preforming a task near the genitals, do so in a professional manner and explain what you are doing (inprofessional terms).
Brief acts or behaviors not helpful. This can be intentional or unintentional.
Ex: hugging a crying patient. Only do this if it meets thier personal needs and not your own.
Negligence by a professional person that creates harm to a person.
Reporting & Recording
- Any change in condition.
- When you leave for breaks/meals.
- Before end of shift
Tips for reporting:
- When reporting, give person’s full name, room number, and bed number.
- What you observed and time of observation.
- Report only what you observed, or did yourself.
Recording is the written account of care and observations.
- Always use ink.
- Always use your name and title when you record. It is important that you use patients full name, room number, etc.
- Don’t skip lines
- Always make sure your recording the right patient.
You will most always record time in 24 hour clock/military time. The following is a conversion.
| Regular Time
|| 24/Military Time
| 12 noon
To add what minute it is put the minutes where the 0’s are: For example 4:32pm would be 1632 in 24 hour clock/military time.
Nutrtion and Fluids
the most important nutrient. It is needed for tissue growth and repair. Sources include: meat, fish, poultry, eggs, milk, and milk products, cereals, beans, peas, and nuts.
Provide energy and fiber for bowel elimination.
Provide energy, they add flavor to food and help the body use certain vitamins.
are needed for certain body functions. They don’t provide calories. The body stores vitamins A, D, E & K.
are used for body processes needed for bone and teeth formation, nerve and muscle function, fluid balance and other processes.
is needed for all body processes.
Doctors may order spacial diets for patients.
- Sodium Controlled – daily sodium of 3000 to 5000 mg.
- Diabetes Meal Plan – For people with diabetes.
- Dysphaga Diet – The doctor, speech therapist, or occupational therapist choose right thickness. This is for someone who has difficulty swallowing.
Normal Fluid Requirements
Adults need 1500ml of water daily to survive. About 2000 to 2500ml of fluid is needed for normal fluid balance.
Special Fluid Orders
- Encourage Fluids- Encourage patient to drink, increase amount of fluids.
- Restrict Fluids- fluids are limited to certain amount set by doctor.
- Nothing by mouth (NPO) – Person cannot eat or drink by mouth.
- Thickened Liquids – All fluids are thickened, including water.
Caring for the Person
- Always address person by name.
- Never call them by their first name, unless they instruct you.
- Don’t use names like: Honey, sweetie, or grandma.