Good Assessment and Documentation Skills Can Lead to ...
Good Assessment and Documentation Skills Can Lead to Improved Clinical
Outcomes for Patients
Lynda K. Ball, MSN, RN, CNN
Objectives
1. Identify sources of non-dietary sodium that can potentially increase a patient's blood pressure.
2. Discuss how oxygen needs impact a dialysis patient's treatment.
3. Describe the impact of good physical assessment to achieve/exceed benchmark clinical quality indicators.
4. Explain how good documentation can legally protect staff.
06/19/2015
2
Evaluating the Patient
06/19/2015
Source: Jazz Communications 3
Prescription
Definition: ? A written order, especially by a physician, for
the preparation and administration of a medicine or other treatment.
06/19/2015
Source: 4
In Dialysis....
? Dialyzer size ? Bath (e.g., 2 K+, 2.5 Ca++) ? Time ? Blood flow rate ? Needle gauge ? Medications ? Standing orders
06/19/2015
5
NURSING ASSESSMENT
06/19/2015
6
Evaluating the Patient
8/6/2014
Source: Jazz Communications 7
Nursing Considerations
? Assessment of patients on hemodialysis:
Pre-dialysis Intradialytic Post-dialysis
? Sodium modeling ? Essential laboratory values ? Anemia management ? Hematocrit-based blood volume monitoring ? Morbidities and mortalities related to volume retention ? Patient education ? Correct weight documentation pre- and post-dialysis
10/07/2014
8
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