What does it mean to Write a description of the resident or patient prior to your intervention?

Answer 1

Write what you saw, heard, touched, smelled. observed, etc. about a patient before you did anything.

Upon walking into Ms. Kibble's room, I observed that one of each of her legs were sticking out of the guardrails, both sides of the bed. She had last been checked 20 minutes ago. Both upper and lower rails (2 on each side) were up and locked. Her right arm was through the bed rail on the right and the urinary catheter tubing was clutched in her right palm. All 4 soft restraints were on but had loosened. A puddle of urine had leaked onto the floor. IV site in left hand intact and patent without signs of redness, heat or infiltration. Patient screaming "Momma, momma, help me!" Noted patient's skin is hot, dry. Temp 100.8 B/P 100/60 Pulse 88 Resp 20. Patient's urinary catheter still in place, and bed dry. With assistance of RN and 2 staff, patient was untangled from guard rails. Patient moved to and repositioned in another bed and moved to a new room. Pt. given water by mouth PRN. Soft restraints reapplied. RN re-secured IV and contacted physician for new orders. Assisted RN to remove paper and plastic garbage after she replaced urinary catheter. Old room disinfected.

(Next note, follow up on what she is "like" in 15 minutes.)