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Debra Collins
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As CEO and President of LTCS Books, Inc., Debra maintains a knowledge base and writes weekly articles on long term care and home health care federal regulatory changes.

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Documenting and Reporting Care and Vital Signs

This inservice is designed for long term care nursing assistants, CNA's, and home health aides, and gives guidelines for receiving resident and client care reports and assignments and properly reporting and documenting care and changes of condition. Detailed charting instructions are outlined. Directions are provided for taking pulse rate, apical pulse rate, blood pressure, respiratory rate, and oral, rectal, axillary, and aural temperature.

Objectives

On completion of this course, the participant will be able to:

  1. Name three subjects covered in an oral shift nursing assistant report.
  2. List seven items included in a written nursing assistant assignment.
  3. Describe contents of resident or client care instructions.
  4. Explain what changes of resident or client condition to report to the charge nurse.
  5. List five main principles of charting resident or client care.
  6. Explain appropriate charting methods.
  7. Describe how to correct charting errors.
  8. List three subjects that should not be charted in care or treatment records.
  9. Outline appropriate technique for taking oral temperature, rectal temperature, axillary temperature, aural temperature, pulse rate, respiratory rate, apical pulse rate, and blood pressure.

Curriculum

Chapter 1
Introduction

Chapter 2
Getting Reports and Assignments

  • Oral Shift Report
  • Written Assignment
  • Resident and Client Care Instructions

Chapter 3
Giving Report
  • Reporting to the Charge Nurse
  • Changes in Condition to Report

Chapter 4
Charting in the Treatment Record
  • Main Principles of Charting
  • General Charting Guidelines
  • Errors in Charting
  • Things You Must Not Do When Charting

Chapter 5
Vital Signs
  • General Practices
  • Temperature
  • Fever
  • Types of Thermometers
  • Oral Temperature
  • Rectal Temperature
  • Axillary Temperature
  • Aural (Tympanic) Temperature
  • Pulse Rate
  • Respiration Rate

Chapter 6
Apical Pulse
  • Preparing to Read an Apical Pulse
  • Reading an Apical Pulse

Chapter 7
Blood Pressure
  • Systolic and Diastolic Pressures
  • Range of Blood Pressure
  • Preparing for BP Measurement
  • Placing the Blood Pressure Cuff
  • Finding the Brachial Pulse
  • Reading BP on a Manual Monitor
  • Reading BP on a Digital Monitor

References

Course Snapshot

Cost: $ 10.00
Contact Hours: 1.25



Accreditation

Upon successful completion the Home Health Aid or Nurse Assistant will receive a Certificate of Completion for 1.25 inservice contact hours.
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