Question

1. List the guidelines for effective documentation. Describe the purpose of the various formats that exist for documenting care.

2. Explain variations in techniques for assessing vital signs in adults vs. an infant vs child. (Example – where to take the temperature or the blood pressure)

3. Pain Assessment Scales for Adults and Peds

Answer 1

1)

#. The purpose of documentation is to: Describe the use, operation, maintenance, or design of software or hardware through the use of manuals, listings, diagrams, and other hard- or soft-copy written and graphic materials.

2) INFANT (up to 1yr)- check resps 1st (a disturbed baby with cry and breath harder) Temp-rectally (last) Pulse- listen to chest (apical) No BP in infants

CHILD (1-12) Pulse and Resp at same time radial pulse keep hold then count resp w/o them knowing. Temp-tempanic (ear) or temporal, axillary or oral depending on child BP- correct size cuff, prepare child that their arm is going to get a "hug"

ADULT-(12 and up, size of cuff depend on size of pt) Temp-orally, tempanic, axillary Pulse- radial Resp-counted after pulse BP-size of cuff.

3) Pain assessment scales used in children:

-Wong-Baker FACES

-Oucher paine scale

-CRIES pain scale

-COMFORT scales

-FLACC scale

May use w/ other ppl that have disabilities or a disease

Wong-Baker FACES

Compare faces ranging from a broad smile- tearful face

Oucher pain scale

developed: Beyer, for young patients

-combines a 0-to-100 scale w/ 6photographic images of children in pain

CRIES pain scale

Intended use for neonates &infants from 0-6 months

COMFORT scale

assess pain and distress in critically ill pediatric patients on :

6 behavioral & 2 physiologic factors

FLACC scale

designed for infants & children (2month-7 years)

-Unable to validate the presence/ severity of pain

5 CATEGORIES: 0-to-2 scale

> F (faces)

> L (legs)

> A (activity)

> C (cry)

> C (consolability)

#. Pain scale for older people:

-wong baker

- Numeric Rating scale

-VAS

-Verbal description

-FPS-R (Face Pain Scale-Revised)

may prefer Vertical pain scale (like the lowa Pain thermometer)