Understanding normal growth and development helps nurses predict, prevent, and detect deviations from patient expected patterns Growth is the physical changes that occur from the prenatal period through older adulthood and includes advancement and deterioration. Development is the biological, cognitive, and socioemotional changes that beginning at conception and continue throughout life; development is dynamic and includes progression. Disease processes can cause developmental delays or regression.
Repeated success through developmental stages results in health promotion, repeated failures can cause inadequacies Freud’s 5 stages of psychosexual development. Stages r characterized by sexual pleasure in the mouth, anus, and genitals. He said adult personality results from how individual resolved conflicts between sources of pleasure and the mandates of reality. 5 stages are oral, anal, phallic or oedipal, latency, genital. Again, oral, anal, phallic or oedipal, latency, genital. Erikson, a follower of Freud, believed development occurred throughout life, and focused on psychosocial stages, not psychosexual stages.
Erikson’s psychosocial development, particular tasks r accomplished before mastering the stage and progressing to the next. 8 stages- trust vs. mistrust (0-1 yr. ) successful resolution of this stage requires a consistent caregiver who is available to meet his needs. From this trust in parents, the infant is able to trust himself, others, and the world, resulting in faith and optimism. Autonomy vs. shame and doubt (1-3 yrs. ) toddlers are learning autonomy and some self-care in this stage resulting from maturation and imitation. Limiting choices or enacting harsh punishments in this stage leads to shame and doubt.
Mastery of this stage achieves self-control and willpower. Initiative vs. guilt (3-6 yrs. ) fantasy and imagination allow them to explore their environment; also developing conscience, or super-ego. limitation causes feelings of frustration and guilt. Mastery results in direction and purpose. Teaching impulse control and cooperation helps to avoid the risks of altered growth and development. Industry vs. Inferiority (6-11 yrs. ) learning to work and play with peers. Without support, or if skills are too difficult, they develop a sense of inadequacy and inferiority. Adult attitudes on work traced to successful achievement.
Identity vs. role confusion (puberty) dramatic physiological changes with sexual maturation occur. “Who am I ? ” stage. Mastery results in devotion and fidelity to others and own ideals. Intimacy vs. isolation (young adult) search for meaningful friendships and intimate relationships. If unable to, isolation results due to fear of rejection and disappointment. Generativity vs. self-absorption and stagnation (middle age) follows development of intimate relationship, adult focuses on supporting future generations through parenthood, teaching, and community involvement. Inability to play a role results in stagnation.
Integrity vs.despair (old age) older adults review lives and feel satisfaction and accomplishment, or despair and regret. Piaget, was interested in children’s intellectual organization: how they think, reason and perceive. Piaget’s theory of cognitive development’s 4 stages: sensorimotor (0-2 yrs. ) learns self and environment through motor and reflex actions. Schemas include hitting, grasping, kicking, looking. learns object permanence. Pre operational (2-7 yrs. ) learn to think using symbols and mental images. exhibit egocentrism, seeing objects and people only from their point of view. demonstrates animism.
Concrete operations (7-11 yrs.) able to describe a process without actually doing it. Formal operations (11-adulthood) self-consciousness, realizing they are unique, and feeling invincible. Chapter 13 Psychosocial changes, ages 29-34, focus is on career. Successful employment ensures economic security, leads to friendships, social activities, support, and respect from coworkers. Chapter 14 Polypharmacy is the use of many medications, it increases risk of adverse drug effects. Question the efficacy and safety of combinations of prescribed meds and advocate for pt. to prevent adverse reactions. Some adults take meds incorrectly, they don’t understand instructions.
Pts. may not remember to take meds as scheduled. Advocating includes finding generic meds for budget. Teach elderly pts. the names of meds, when and how to take, and effects. Use special care when administering meds used to treat confusion, and use nonpharmacologic treatments in addition to meds. Chapter 15 Components of critical thinking in nursing 1. specific knowledge base, 2. Experience, 3. Critical thinking competencies, 4.
Attitudes for critical thinking (confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility, 5. standards for critical thinking Reflective journaling, reflection is the process of purposefully recalling a situation to discover its purpose or meaning. Reflective journal writing is for developing critical thought and reflection by clarifying concepts, and gives the opportunity to define and express the clinical experience in your own words.
Concept mapping, a visual representation of patient problems and interventions that shows the relationships to one another. primary purpose is to synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures.
Chapter 16 Cue, information that you obtain through use of the senses. Inference, your judgement or interpretation of these cues 11 functional health patterns – 1. Health perception-health management pattern 2. Nutritional metabolic pattern 3. Elimination pattern 4. Activity-exercise pattern 5. Sleep-rest pattern 6. Cognitive perceptual pattern 7. Self-perception self-concept pattern 8. Role relationship pattern 9. Sexuality reproductive pattern 10 coping-stress tolerance pattern 11.
Value-belief pattern Sources of data: patient, family, health care team, medical records, other records and scientific literature, nurse’s experience Patient-centered interview, for obtaining pt. data to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness. It includes: 1. Setting the stage (orientation phase) explain the reason for collecting health history and assure confidentiality. 2. Set an agenda- focus on patient’s concerns. 3. Collect the assessment or health history 4. Terminate the interview, summarize your discussion with the pt. and check for accuracy. good time for the pt. to ask questions.
Open ended questions, do not presuppose answers, and prompt patients to describe in more than 1 or 2 words. “so why did you come to the hospital today? ” “tell me about the problems you’re having” Back channeling, reinforce your interest in what the patient has to say through the use of good eye contact and listening skills; use listening prompts such as “all right” “go on” or “uh huh” Probing, encourage a full description without trying to control the direction the story takes. “is there anything else you can tell me? ” “what else is bothering you? ” Closed-ended questions, limit s answers to 1 or 2 words, or a number or frequency of a symptom. “how often does diarrhea occur? ” “do you have pain or cramping? ”
Nursing health history includes: biographical information, reason for seeking health care, patient expectations, present illness or health concerns, health history (especially allergies!! ), family history, environmental history, psychosocial history, spiritual health, review of systems (ROS)- a systematic approach for collecting the patient’s self-reported data on all body systems, documentation of systems Concomitant symptoms, other symptoms along with the primary symptom eg: nausea with pain?
Chapter 17 Medical diagnosis, the identification of a disease condition based on a specific evaluation of physical signs, symptoms, patients medical history, and the results of diagnostic tests and procedures. Nursing diagnosis, a clinical judgment about individual, family, or community responses (eg: nausea, pain) Nanda, NANDA, north American nursing diagnosis association
Data cluster, a set of signs or symptoms gathered during assessment that you group together in a logical way Related factor, a condition, historical factor, or etiology that gives a context for defining characteristics and shows a type of relationship with the nursing diagnosis Actual nursing diagnosis, describes human responses to health conditions or life processes that exist in an individual, family, or community Risk nursing diagnosis, describes human responses to health conditions or life processes that may develop in a vulnerable individual, family or community.
Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem Health promotion nursing diagnosis, a clinical judgment of a person’s, family’s, or community’s motivation, desire and readiness to increase wellbeing and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise.
The related factor is identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis The PES format, Problem, etiology or related factor, symptoms or defining characteristics Sources of diagnostic error, Collecting (lack of knowledge or skill, inaccurate data, missing data), interpreting (inaccurate interpretation of cues, insufficient number of cues, unreliable or invalid cues), Clustering (insufficient cluster of cues, premature or early closure, incorrect clustering), Labeling (wrong diagnostic label selected, evidence that another diagnosis is more likely, failure to seek guidance)
Guidelines to reduce errors in diagnostic statement: 1. Identify patient’s response, not medical diagnosis. 2. Identify Nanda diagnostic statement rather than the symptom 3. Identify treatable etiology or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing diagnosis. 4. Identify problem caused by the treatment or diagnostic study rather than the treatment or study itself. 5. Identify patient response to equipment rather than the equipment itself. 6.
Identify patient’s rather than your problems with nursing care. 7. Identify patient problem rather than nursing intervention. 8. Identify patient problem rather than goal of care. 9. Make professional rather than prejudicial judgments. 10. Avoid legally inadvisable statements. 11. Identify problem and etiology to avoid circular statements. 12. Identify only one patient problem in the diagnostic statement.
Chapter 18 Classify patient’s priorities high, intermediate, or low. High priorities are sometimes both physiological and psychological and may address other basic needs. Intermediate priority involves non emergent, non-life threatening needs. Low priority diagnoses focus on long term health care needs.
A goal is a broad statement describing desired change in a patient’s condition or behavior An expected outcome is a measurable criterion to evaluate goal achievement patient centered goals reflect highest possible level of wellness and independence in function, is realistic and based on needs and resources. A short term goals are objective behavior or responses patient is to achieve in usually less than a week.
A long term goals r objective behavior or responses patient is to achieve over several days, weeks, or months A nursing sensitive patient outcome is a measurable patient, family or community state, behavior, or perception, largely influenced by and sensitive to nursing interventions. Guidelines for writing goals and expected outcomes: patient centered, singular goal or outcome, observable, measurable, time limited, mutual factors (patient and nurse agree), realistic Independent nursing interventions, nurse initiated, do not require an order from another health care professional (elevating an extremity, repositioning a patient, educating patients).
Dependent nursing interventions, physician initiated, based on the physician’s response to treat or manage (administering meds, performing an invasive procedure, changing a dressing) Collaborative interventions or interdependent interventions, are therapies requiring combined knowledge, skill, and expertise of multiple health care professionals.
Critical pathways are patient care management plans providing health care team with activities and tasks to put into practice sequentially. Planning involves consultation with members of health care team. Consultation occurs at any step in the process, most often during planning and implementation. Consultation is seeking the expertise of a specialist to identify ways to handle a problem in patient management or planning and implementation of therapies. Chapter 19 Nursing intervention, treatment based on clinical knowledge and judgment that nurse performs to enhance patient outcomes.
A clinical practice guideline is a set of statements helping nurses, physicians, and other health care providers make decisions about health care for specific clinical situations Protocol outlines conditions that nurses can treat such as controlled hypertension and types of treatment they are permitted to administer such as anti-hypertensive meds. Examples include protocols for admission and discharge, pressure ulcer care, and incontinence management. A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and diagnostic procedures for specific patients with identified clinical problems NIC system helps to differentiate nursing practice from that of other health care professionals.
The NIC interventions offer a level of standardization to enhance communication of nursing care across settings and compare outcomes. ANA standards of professional practice are to be used as evidence of the standard of care that registered nurses provide their patients. Assessment is a continuous process that occurs each time you interact with the patient. continuous Risk to patients come from both illness and treatment. It is the nurse’s job to look for and recognize these risks, and adapt interventions. Cognitive skills involve the application of critical thinking in the nursing process. Interpersonal skills are essential for effective nursing action. Psychomotor skills require the integration of cognitive and motor activities.
Direct care, activities of daily living (bathing, toileting, eating), instrumental activities of daily living (shopping, preparing meals, house cleaning, taking meds), physical care techniques (turning and positioning, administering meds, providing comfort measures), lifesaving measures (CPR, emergency meds, intervening to protect a patient), counseling, teaching, controlling for adverse reactions, preventive measures (promotion of health and wellness) Indirect care, documentation, delegation of care, order transcription, infection control, environmental safety management, change of shift report, collecting, labeling and transporting specimens Chapter 20.
A goal is the expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state Evaluation is an ongoing process. Ongoing. Chapter 21 Nursing care delivery models: team nursing- RN, LPN, CNA, PCT, total patient care- RN is responsible for all aspects of care. primary nursing, one primary RN assumes care for a caseload of patients Decentralized management, decision making is moved down to the level of staff, very common within organizations. Responsibility, the duties and activities that an individual is employed to perform. Autonomy, freedom of choice and responsibility for the choices. Authority, legitimate power to give commands and make final decisions specific to a given position.
Accountability, individuals being answerable for their actions The nursing manager supports staff involvement through a variety of approaches: 1. Establishing nursing practice or problem solving committees or professional shared governance councils 2. Nurse/physician collaborative practice 3. Interdisciplinary collaboration 4. Staff communication 5. Staff education Clinical care coordination: clinical decisions, priority setting (high-immediate or life threatening, intermediate non-emergent, non-life threatening, low-problems not directly related to disease or illness), organizational skills, use of resources, time management, evaluation Evaluation is an ongoing process; compares actual patient outcomes with expected outcomes.
When expected outcomes are not met, evaluation reveals the need to continue current therapies, revise approaches to care, or introduce new therapies. Evaluation orientation ensures good patient outcomes Delegation is transferring responsibility for the performance of an activity or task while retaining accountability for outcomes. It results in quality patient care, improved efficiency, increased productivity, empowered staff, and development of others, and provides job enrichment. NEVER delegate a task that you dislike doing or would not do independently because this creates negative feelings and poor working relationships. do not delegate the steps of the nursing process to a NAP, because these steps require nursing judgment.
to a NAP you delegate tasks, not patients. know which skills you are able to delegate. be familiar with nurse practice act, institutional policies and procedures, and job descriptions for the NAP provided by the institution. These define the necessary level of competency of NAP. Handoff disconnects, lack of knowledge about the workload of team members, and difficulty dealing with conflict are examples of communication failures resulting in delegation ineffectiveness and omission of nursing care. Important, evaluate the staff member’s performance, achievement of the patient’s outcomes, the communication process used, and any problems or concerns.
Tips on delegation: assess the knowledge and skills of the delegatee, match tasks to the delegatee’s skills, communicate clearly, listen attentively, provide feedback The 5 rights of delegation: right task, right circumstances, right person, right direction/communication, right supervision/evaluation.
The 5 rights of delegation: right task, right circumstances, right person, right direction/communication, right supervision/evaluation Chapter 24 to communicate effectively, u need curiosity (to know more about a person), self-confidence, an independent attitude (to communicate with colleagues and share ideas about nursing interventions), an attitude of fairness (to listen to both sides of a discussion), integrity (to recognize when their opinions conflict and decide how to reach mutually beneficial decisions, and humility.
Perceptual biases, tendencies that interfere with perceiving and interpreting messages. don’t assume others think, feel, act, react, and behave as u would. Intrapersonal communication, occurs within an individual, called self-talk, self-verbalization, or inner thought. it provides mental rehearsal for difficult tasks or situations to deal with them more effectively and with increased confidence. Interpersonal communication, one-on-one interaction between nurse and another, often occurs face to face. frequently used in nursing situations, at the heart of the nursing practice. includes all the symbols and cues.
Transpersonal communication, occurs within a person’s spiritual domain. prayer, meditation, guided reflection, religious rituals, to communicate with their higher power. Small group communication, when a small number of persons meet. is usually goal directed and requires an understanding of group dynamics.
Public communication is interaction with an audience. requires special adaptations in eye contact, gestures, voice inflection, and use of media materials. Elements of communication: Referent- motivates one person to communicate with another. In health care settings sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, and other cues initiate communication Sender, the person who encodes and delivers the message.
Receiver, the person who receives and decodes the message. The sender’s message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the sender’s message. Message, the content of communication. Channels are means of conveying and receiving messages. Feedback is the message the receiver returns. Interpersonal variables, factors within sender and receiver that influence communication. Environment, the setting for the sender-receiver interaction. Forms of communication: verbal, uses spoken or written words. Nonverbal, includes the 5 senses and involves anything that does not use spoken or written word.
Types of verbal communication: vocabulary, pace, intonation, denotative and connotative meaning, the connotative meaning is the shade or interpretation of the meaning of a word influenced by thoughts, feelings, or ideas people have about the word. carefully select words, avoid misinterpreted words. Clarity and brevity, effective communication is simple, brief, and direct.
Timing and relevance, timing is critical. The best time is when patient expresses interest in communicating. Also, messages relevant to situation at hand, are more effective. Types of nonverbal communication: (55% is transmitted by body cues). Personal appearance, posture and gait- (way of walking) are forms of self-expression. Facial expression, eye contact, gestures, sounds, territoriality and personal space.
Symbolic communication, verbal and nonverbal symbolism used by others to convey meaning (art, music, dance). Meta-communication, refers to all factors that influence communication. Zones of personal space: intimate (0-18”) eg: holding an infant, changing a dressing, bathing a patient. Personal (18”-4ft) eg: sitting at patient’s bedside, teaching a patient Social (4-12 ft. ) making rounds with a Dr. , sitting at the head of a conference table, teaching a class. Public (12+ft) speaking at a community forum, testifying at a hearing, lecturing to a class. Zones of touch: social zone, hands, arms, shoulders, back. Consent zone, (permission needed) mouth, wrists, feet. Vulnerable zone, (special care needed) face, neck, front of body.
Intimate zone, (great sensitivity needed) genitalia, rectum. Phases of the helping relationship: Pre-interaction phase, (before meeting pt. ) review history and data, talk with other caregivers, anticipate concerns or issues, identify a location that is comfortable and private, plan enough time for initial interaction.
Orientation phase (when the nurse and pt. meet and get to know each other) set a warm, caring tone, realize that initial interaction may be uncertain or tentative, expect pt. to test your competence and commitment, assess pt. ’s health status Working phase (when the nurse and pt. work together to solve problems and accomplish goals) encourage pt.to express feelings on health, encourage self-exploration, provide information, encourage pt. to set goals.
Termination phase (during the ending of the relationship), remind pt. that termination is near, evaluate goal achievement with pt. , reminisce about the relationship, relinquish responsibility of care to pt. Therapeutic communication techniques encourage the expression of feelings and ideas and convey acceptance and respect. Active listening, being attentive to what the pt. is saying both verbally and nonverbally: Soler. S sit facing the patient O observe an open posture L lean toward the pt. E establish and maintain intermittent eye contact R relax Chapter 25.
Purposes of patient education: to help individuals, families, or communities achieve optimal levels of health. Maintenance and promotion of health and illness prevention, restoration of health, coping with impaired functions. Teaching is an interactive process that promotes learning. Learning is acquisition of new knowledge, attitudes, behaviors, and skills. Role of nurse in teaching and learning: “SPEAK UP” tips to help patients become more involved in their treatment.
S speak up if you have questions or concerns P pay attention to the care you get E educate yourself about your illness A ask a trusted family member or friend to be your advocate K know which medicines you take and why you take them U use a hospital, clinic, surgery center, or health care organization that has been carefully evaluated P participate in all decisions about your treatment.
Motivation to learn, physical discomfort, anxiety, and environmental distractions affect a pt. ’s ability to focus and comprehend learning. first ensure pt. is able to focus. Mild anxiety promotes learning, but high anxiety prevents learning. anxiety must be managed before educating. Motivation causes a person to behave in a particular way. If a person does not want to learn, it is unlikely that learning will occur. sometimes comes from a social, task mastery, or physical motive. Ability to learn, cognitive development influences the pt. ’s ability to learn. know the pt. ’s level of knowledge and intellectual skills before beginning.
Goals and outcomes, goals indicate that a pt. achieves a better understanding of information and is able to attain health or better manage illness. When developing outcomes, conditions and time frames need to be realistic and meet patient needs. settings influence the complexity of the teaching plan.
Acute care setting plans are concise and focused on the primary learning needs of the pt. , whereas home care and outpatient clinic teaching plans are more comprehensive in scope because you have more time to instruct patients and patients are often less anxious in these settings. Telling, use this approach when teaching limited information (eg: preparing a pt.for a diagnostic procedure) there is no opportunity for feedback with this method Participating, in this approach the nurse and pt. set objectives and become involved in the learning process together.
Entrusting, this approach provides the pt. the opportunity to manage self-care Reinforcing, requires using a stimulus to increase probability of response. Positive reinforcement such as a smile or spoken approval produces desired responses. Although negative reinforcements such as frowning or criticizing decreases an undesired response, people usually respond better to positive reinforcement. The effects of negative reinforcement are less predictable and often undesirable. Three types of re-enforcers: social, material and activity
Social, used to acknowledge a learned behavior (smiles, compliments, encouragement) Material, food, toys, music (work best with young children) Activity, rely on a person’s motivation to engage in an activity if he has the opportunity to engage in a more desirable activity after completion of the task. Observing behavior often helps to reveal the best reinforcer to use Instructional methods, choose instructional methods that match a pt. ’s learning needs, the time available for teaching, the setting, the resources available, and your comfort level with teaching. One-on-one discussion, usually informal, and can take place at a pt. ’s bedside. Group instruction, to teach a number of patients at once, enables patients to interact and learn from others experiences.
Preparatory instruction, providing information about procedures often decreases anxiety because the patients have a better idea of what to expect during the procedure, which helps give them a sense of control. (eg: explain the physical sensations during the procedure, describe the cause of the sensations, prepare patients only for aspects of the experience that are commonly noticed. ) Demonstrations, use demos when teaching psychomotor skills such as preparation of a syringe, bathing an infant, crutch walking, or taking a pulse. most effective when learners first observe the teacher and then, have a chance to practice a return demonstration. Chapter 26 DOCUMENTATION (SUPER DUPER IMPORTANT)- anything written or printed on which you rely as record or proof of pt. actions and activities.
Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice. Common charting mistakes resulting in malpractice: 1. Failing to record pertinent health or drug information 2. Failing to record nursing actions 3. Failing to record that medications have been given 4. Failing to record drug reactions or changes in patient’s condition 5. Writing illegible or incomplete records 6. Failing to document discontinued meds Guidelines for quality documentation: Factual, a factual record contains descriptive, objective information about what a nurse sees, hears, feels and smells.
An objective description is the result of direct observation and measurement. Avoid vague terms that suggest you are sharing opinion (eg: appears, seems, apparently) The only subjective data included is what the patient says. Document the patient’s exact words, use quotations if possible. Accurate, use of exact measurements. (eg: intake, 360 ml of water) Critical pathways, interdisciplinary care plans that include problems, interventions, and expected outcomes within a time frame. they eliminate nurse’s notes, flow sheets, and nursing care plans because the document integrates all relevant information. Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway are called variances.
A variance occurs when the activities on the critical pathway are not completed as predicted or the pt. does not meet the expected outcomes. A positive variance occurs when a patient progresses more rapidly than expected. A variance analysis is necessary to review for trends and for developing and implementing an action plan to respond to the problems. Once you identify a variance, you modify the pt. ’s care to meet the needs associated with the variance. Over time, health care teams sometimes revise critical pathways if similar variances reoccur. Discharge summary forms, to save costs and ensure appropriate reimbursement, it is important to prep patients for an effective and timely discharge from a health care institution.
A pt. ’s discharge also needs to result in desirable outcomes. Interdisciplinary discharge planning ensures a patient leaves the hospital in a timely manner with the necessary resources. Pt. and family should be involved in discharge planning so they have the necessary information and resources to return home. Discharge documentation includes medications, diet, community resources, follow up care, and who to contact in case of an emergency or for questions. Home care documentation, Medicare has specific guidelines to establish eligibility for home care reimbursement. Information used for reimbursement comes from the patient’s medical records.
Documentation is both the quality control and the justification for reimbursement. Information in the home care medical record includes pt. assessment, referral and intake forms, interprofessional plan of care, list of meds, and reports to 3rd party payers. Long term health documentation, Medicaid and Medicare guidelines require careful documentation for appropriate reimbursement in long-term care agencies. When residents’ records are reviewed for reimbursement, there is expectation that protocols such as skin assessments, wound care, and assisted ambulation are met. Incidence reports, an incident is any event that is not consistent with the routine operation of a health care unit or routine care of a patient.
Incidents include falls, needle sticks, visitors with illness, medication admin errors, accidental omission of ordered therapies, and circumstances that lead to injury or a risk for patient injury. Analysis of reports help identify trends in operations that provide justification of changes in policies and procedures. Incident reports are a part of the quality improvement program. Always contact the pt. ’s health care provider whenever an incident happens. NOTE THAT YOU DO NOT MENTION THE INCIDENT REPORT IN THE PATIENT’S MEDICAL RECORD. Instead, you document an objective description of what happened, what you observed, and follow up actions to be taken in the pt. ’s medical record. It is important to evaluate and document the pt. ’