lOMoARcPSD|26582732
Capstone fundamentals 2025
Types of documentation
Focused charting – documents abnormal findings, e.g. Pt has a fever ~
temperature will be documented. If vitals are not present, this would there is no
abnormality in vs.
Pei charting – problems, intervention and evaluation will be documented.
Soapie charting – subjective data, objective, assessment, problem,
implementation (intervention), evaluation
Scenario: do not document in patient chart before doing it. This is known as
documentation record. Always document in military time e.g. 1800 hours, 1300
hours etc.
Scenario: after documenting, you realize an error was made ~ draw a single line
(strike through) with initials and date and note error. This is because we cannot
make changes to documentations. Do not use white out.
Patient safety and quality
Yellow ~ fall risk red ~ allergies purple ~ dnr order (do not resuscitate)
Fall prevention: strategies include lower bed at the lowest position, fall
prevention mattress, clutter free, do not use throw rugs, grip bars in the
bathroom and dim lights in patient’s room. If all side rails are raised, this is
considered as a form of restraint. Raise only two. For these types of patients, give
room closest to the nurse’s station.
Restraint: doctor’s order is needed to apply restraint and is only valid for 24
hours. The nurse should perform neurovascular checks. If a physical restraint,
release patient for every 2 hours.
Scenario: you are educating a cna on how to tie restraint, never tie to the side of
the side rail. Always tie to the non- movable part of the cord. (where urine bag is).
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Tie in the form of a half sleeve knot (easily untied) and must be out of reach from
patient.
Scenario: if there is a fire in the unit, “remember race”. Remove patients that are
in immediate danger, activate fire alarm, confine the fire (close windows and
doors, turn off oxygen source), use a fire extinguisher.
How to use fire extinguisher: “pass” ~ pull the pin, aim the nozzle at the base of
fire, squeeze the lever slowly and sweep from side to side.
Care of patient with seizure
If patient is having a seizure, ease them on the floor. During a generalized seizure,
pt. Will become unconscious. If on the bed, raise side rails, remove all hazards,
never try to restraint seizure during a seizure. Keep airway clear. Turn patient
head to the side, timed the seizure, not the duration. If longer then 5 minutes
and no consciousness, contact emergency services. Darken room (dim light),
avoid loud sound will trigger a seizure.
Workplace violence ~ if this happens, write an incident report. (not common)
Infection prevention and control
Most effective method of preventing infection ~ handwashing that last from 15 –
20 seconds. If hands are visibly soiled, use soap and water. If not visibly soiled,
used alcohol-based hand rub.
Asepsis ~ absence of infection.
Types of asepsis: medical (follows a clean technique) + surgical
Asepsis (follows a sterile technique)
Reservoir of infection: patient has tb, the lungs are considered a reservoir of
infection.
Stages of an infectious disease; incubation, prodromal stage, illness stage,
convalescent stage.
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Capstone fundamentals 2025
Types of documentation
Focused charting – documents abnormal findings, e.g. Pt has a fever ~
temperature will be documented. If vitals are not present, this would there is no
abnormality in vs.
Pei charting – problems, intervention and evaluation will be documented.
Soapie charting – subjective data, objective, assessment, problem,
implementation (intervention), evaluation
Scenario: do not document in patient chart before doing it. This is known as
documentation record. Always document in military time e.g. 1800 hours, 1300
hours etc.
Scenario: after documenting, you realize an error was made ~ draw a single line
(strike through) with initials and date and note error. This is because we cannot
make changes to documentations. Do not use white out.
Patient safety and quality
Yellow ~ fall risk red ~ allergies purple ~ dnr order (do not resuscitate)
Fall prevention: strategies include lower bed at the lowest position, fall
prevention mattress, clutter free, do not use throw rugs, grip bars in the
bathroom and dim lights in patient’s room. If all side rails are raised, this is
considered as a form of restraint. Raise only two. For these types of patients, give
room closest to the nurse’s station.
Restraint: doctor’s order is needed to apply restraint and is only valid for 24
hours. The nurse should perform neurovascular checks. If a physical restraint,
release patient for every 2 hours.
Scenario: you are educating a cna on how to tie restraint, never tie to the side of
the side rail. Always tie to the non- movable part of the cord. (where urine bag is).
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
Tie in the form of a half sleeve knot (easily untied) and must be out of reach from
patient.
Scenario: if there is a fire in the unit, “remember race”. Remove patients that are
in immediate danger, activate fire alarm, confine the fire (close windows and
doors, turn off oxygen source), use a fire extinguisher.
How to use fire extinguisher: “pass” ~ pull the pin, aim the nozzle at the base of
fire, squeeze the lever slowly and sweep from side to side.
Care of patient with seizure
If patient is having a seizure, ease them on the floor. During a generalized seizure,
pt. Will become unconscious. If on the bed, raise side rails, remove all hazards,
never try to restraint seizure during a seizure. Keep airway clear. Turn patient
head to the side, timed the seizure, not the duration. If longer then 5 minutes
and no consciousness, contact emergency services. Darken room (dim light),
avoid loud sound will trigger a seizure.
Workplace violence ~ if this happens, write an incident report. (not common)
Infection prevention and control
Most effective method of preventing infection ~ handwashing that last from 15 –
20 seconds. If hands are visibly soiled, use soap and water. If not visibly soiled,
used alcohol-based hand rub.
Asepsis ~ absence of infection.
Types of asepsis: medical (follows a clean technique) + surgical
Asepsis (follows a sterile technique)
Reservoir of infection: patient has tb, the lungs are considered a reservoir of
infection.
Stages of an infectious disease; incubation, prodromal stage, illness stage,
convalescent stage.
Downloaded by NELSON KIIRU ()
