NURSING DOCUMENTATION

and

PREPARED BY:

REMINA G. AYSON R.N.

WHAT
IS

NURSIN G?

NURSING
> the diagnosis of human responses to actual and potential problems. -- American Nurses Association > the act of utilizing the environment of the patient to assist him in his recovery. -- Florence Nightingale > to assist the individual sick or well. -- Virginia Henderson

Common Themes: 
Nursing is Caring. Nursing is an Art. Nursing is Science. Nursing is Client-Centered. Nursing is Holistic. Nursing is Adaptive. Nursing is concerned with health Promotion, Health Maintenance and Health Restoration. Nursing is a Helping Profession.

DOCUMENTATION -is anything written or printed that is relied on as record or proof for authorized person. .

Why is there a need for nursing documentation? ´ Record keeping is an integral part of nursing and midwifery practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow.µ (Nursing & Midwifery Council April 2002) .

care .Good record keeping promotes: ‡High standards of clinical care ‡Continuity of care ‡Better communication & dissemination of information ‡An accurate account of treatment.

Good record keeping is a mark of a skilled and safe practitioner.What is expected of a registered nurse? The quality of your record keeping is a reflection of the standard of your professional practice. .

Record keeping ‡A full account of your assessment and should demonstrate: the care you have planned and provided ‡Relevant information about the condition of the patient at any given time and the measures you have taken to respond to their needs ‡Evidence that you have understood and honoured your duty of care ‡That you have taken all reasonable steps to care for the patient and any action or omission on your part have not compromised their safety ‡A record of arrangements you have made for the continuing care for the patient .

completed upon admission. > Vital signs > Intake and Output 3. Graphic Flowsheet .it allows the nurse to record specific measurements on a repeated basis. Medicine & Treatment record . sex and address > Method of admission 2. .DIFFERENT SHEETS: 1.allows for the repeated recording of medication and treatment of the patient on a repeated basis. > Biographic data > Age. Nursing Health History and Assessment Worksheet .

S ± Series of flips cards kept at a portable index file at the nurse¶s station. Nursing Care Plan . 2 Parts: 1. E ± Ensure continuity of care.4. T ± Tool for communication. Activity and Treatment Section 2. Nursing Kardex R ± Readily accessible.

H ± Health teaching. I ± Instructions about medications and treatment regimen. R ± Record pertinent data. F ± Final physical assessment. A ± Assess the client support system. Discharge Summary .5.helps ensure that the client¶s condition during discharge is in desirable outcome. .

Accurate > The use of exact measurements establish accuracy . objective information about what a nurses sees. > It is essential to avoid the use of unnecessary words and irrelevant details. hears. is not acceptable because these words suggest that the nurse is stating an opinion. 2.Guidelines of Quality Documentation and Reporting: 1. > Documentation of concise data is clear and easy to understand. The use of vague terms such as appears. . seems and apparently. Factual > A record must contain descriptive. feels and smells.

3. Organized > The nurse communicates information in a logical order. 4. To increase accuracy and decrease unnecessary duplication. 5. . containing appropriate and essential information. Current > Timely entries are essential in the clients ongoing care. Complete > The information within a recorded entry or a report needs to be complete. many healthcare agencies use records kept near the client¶s bedside which facilitate immediate documentation of information as it is collected from a client.

˜ Chart consecutively. be sure information is accurate. ‡Do not write retaliatory or critical comments about the client care by other health care professionals. write word error above it and sign your name or initials. if space is left. ‡Do not leave blank spaces in nurse¶s notes. line by line. .Legal Guidelines for Recording: ‡Draw single line through error. client¶s comments should be quoted. ˜ Enter only objective descriptions of client¶s behavior. Then record note correctly. ˜ Avoid rushing to complete charting. ˜Errors in recording can lead to errors in treatment. draw line horizontally through it and sign your name at end. ‡Correct all errors promptly.

felt pen. ˜ If you perform orders known to be incorrect. ‡Chart only for yourself. . record that clarification was sought. ˜Never chart for someone else. you are just as liable for prosecution as the physician is. ‡If order is questioned. ˜Never use pencil.‡Record all entries legibly and in blank ink. ˜ Black ink is more legible when records are photocopied or transferred to microfilm. ˜ You are accountable for information you enter into chart.

˜ Once logged into the computer do not leave the computer screen unattended. and end with your signature and title. ‡For computer documentation keep your password to yourself. empty phrases such as ³status unchanged´ or µhad good day´. .‡Avoid using generalized. ˜Maintain security and confidentiality. ˜ Begin each entry with time. ˜ Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure to sign each entry.

Somethin g that is NOT written is considere d as NOT done at Remem ber! .

NURSI NG PROC ESS .

IMPLEMENTATION and EVALUATION.HISTORY The term NURSING PROCESS was first used/mentioned by Lydia Hall. then a 5-step (ADPIE). DIAGNOSIS. Since then. . nursing process continue to evolve: it used to be a 3-step process. a nursing theorist. in 1955 wherein she introduced 3 STEPs: observation. PLANNING. then a 4-step process (APIE). administration of care and validation. now a 6-step process (ADOPIE) ASSESSMENT. OUTCOME IDENTIFICATION.

organized. systematic and humanistic care) for efficient and effective provision of nursing care. · It is a G O S H approach (goal-oriented. to plan and implement the care and evaluate the result. . · it is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care. organized method of planning.NURSING PROCESS · is a systematic. and providing quality and individualized nursing care.

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*CHARACTERISTIC OF NURSING PROCESS ‡Cyclic and Dynamic in nature ‡Involves skill in Decision-making ‡Uses Critical Thinking skills .

PURPOSE OF NURSING PROCESS: ‡To identify a client¶s health status. his Actual/Present and potential/possible health problems or needs. holistic. ‡To provide nursing interventions to meet those needs. . ‡To provide an individualized. ‡To establish a plan of care to meet identified needs.

Assessment Evaluation Diagnosis Implementation Outcome Identification Planning .

ASSESSMENT First Step in the Nursing Process ‡it is systematic and continuous collection. Purpose: To establish a data base (all the information about the client): ‡nursing health history ‡physical assessment ‡the physician¶s history & physical examination ‡results of laboratory & diagnostic tests ‡material from other health personnel . health practices. health problems. ‡it includes the client¶s perceived needs. validation and communication of client data as compared to what is standard/norm. values and lifestyles. related experiences.

Initial assessment ± assessment performed within a specified time on admission Ex: nursing admission assessment b.4 TYPES OF ASSESSMENT: a. Problem-focused assessment ± use to determine status of a specific problem identified in an earlier assessment Ex: problem on urination-assess on fluid intake & urine output hourly .

d.c. Emergency assessment ± rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. time-lapsed assessment ± reassessment of client¶s functional health pattern done several months after initial assessment to compare the clients current status to baseline data previously obtained. breathing status & circulation after a cardiac arrest. Ex: assessment of a client¶s airway. .

ACTIVITIES Collection of data Validation of data Organization of data Analyzing of data Recording/documentation of data .

Objective Data (Signs) e. 2.g.TYPES OF DATA 1.5 C. warm to touch skin .g.Subjective Data (Symptoms) e. T= 38. I feel hot.

Methods of Data Collection Interview Observation Examination .

SOURCES OF Primary source .DATA client (best source of data) .

-support people. . -health care professionals. records of therapies by other health professionals and laboratory records).g.Secondary sources ² indirect sources e.literature . -client records (medical records. ± family members.

.DIAGNOSIS Second Step in the Nursing Process -the process of reasoning or the clinical act of identifying problems Purpose: To identify health care needs and prepare a Nursing Diagnosis.

Components of a nursing diagnosis: PES or PE Problem statement/diagnostic label/definition = P Etiology/related factors/causes = E Defining characteristics/signs and symptoms = S .

Potential Nursing diagnosis (Problem + Etiology) e.g.Types of Nursing Diagnosis 1. Impaired verbal communication r/t cultural differences as manifested by inability to speak English Alteration in comfort. Actual Nursing Diagnosis (Problem + Etiology + S/S) e.g. Possible low self-esteem r/t loss job Possible altered thought processes r/t unfamiliar surroundings Potential skin breakdown r/t physical immobilization in total body cast . pain / associated with / abdominal incision / as manifested by / muscle guarding and grimace´ Altered thermoregulation. / related to infection / as manifested by / high grade fever and excessive perspiration 2.

g.3. Risk Nursing diagnosis (Problem + Risk Factors) e. ‡Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in diabetes. . ‡Risk for Constipation r/t inactivity and insufficient fluid intake ‡Risk for infection r/t compromised immune system.

With flush skin and warm to touch. warm to touch.2C RR = 35 P = 96.Situation: Madam Mariam. headache and I feel hot also after I finished my laundry. Nsg Dx: ? Hyperthermia r/t environmental condition AMB T = 39C. teary eyed and dry lip and mucous membrane.35 years of laundry woman seeks consultation at the Al Yousif Hospital due to fever 2 days PTA. teary eyed and with dry lips and mucous membrane. . flush skin. She verbalizes: ³I suddenly felt cold and shiver. ³She has 3 children she walks off to school everyday before she goes to work VS: T=39.

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