Y khoa, y dược - Chapter 6: Nurse note documentation

Chapter 6Nurse Note DocumentationLevel 2© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-HillChapter 6 ContentLO 6.1 Dx (Nursing Diagnosis)LO 6.2 NOC (Nursing Outcomes)LO 6.3 NIC (Nursing Interventions)LO 6.4 MAR (Medication Administration Record)LO 6.5 I&O (Intake and Output)LO 6.1 DX (NURSING DIAGNOSIS)LO 6.1 Dx (Nursing Diagnosis)Standardized languageMechanism for communicationReflects nursing practiceFacilitates use of technologyAllows comparison of nursing activitiesUsed in researchPromotes quality patient care12 systems recognized by ANALO 6.1 Dx (Nursing Diagnosis)NANDA-I nursing dx, NOC, NICWidely recognizedResearch basedComprehensiveLO 6.1 Dx (Nursing Diagnosis)Nursing processAssessment/diagnosisPlanningInterventionEvaluationLO 6.1 Dx (Nursing Diagnosis)AssessmentFirst step in nursing processSubjective dataReport of patient and/or familyObjective dataObservations of nurseObservationAuscultationPalpationSmellLO 6.1 Dx (Nursing Diagnosis)Assessment data used to formulate nursing dxNursing diagnosis“Clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes” (NANDA-I)Key = patient response to illnessMedical diagnosisDisease processLO 6.1 Dx (Nursing Diagnosis)Nursing diagnosisPrioritized High priority = Airway, Breathing, Circulation (ABCs)Mid priority = threat to health or ability to copeLow priority = delayed intervention will not cause harmLO 6.1 Dx (Nursing Diagnosis)To assign nursing dxCollect subjective and objective dataAnalyze data to identify actual and potential problemsAssign nursing dxIndividualize nursing dxEtiology (related to)Signs & symptoms (as evidenced by)Place in order of priorityLO 6.1 Dx (Nursing Diagnosis)Research evidenceUse of nursing diagnoses improves documentation of assessmentsInclusion of etiology in nursing dx improves both interventions and outcomesMuller-Staub, M. (2009) “Evaluation of the implementation of nursing diagnoses, outcomes and interventions.” International Journal of Nursing Terminologies and Classifications, 20(1), 9–15.LO 6.2 NOC (NURSING OUTCOMES)LO 6.2 NOC (Nursing Outcomes)Planning phase of nursing processDetermine desired patient outcomesShort term goalsLong term goalsIndividualize for the patientLO 6.3 NIC (NURSING INTERVENTIONS)LO 6.3 NIC (Nursing Interventions)Nursing interventionsNursing actions to help patient achieve goalsFacilitate wellnessFacilitate movement toward wellnessIndividualized for patientLO 6.4 MAR (MEDICATION ADMINISTRATION RECORD)LO 6.4 MAR (Medication Administration Record)The Nursing Documentation area in Spring-Charts allows nurse to use additional documents and/or spreadsheets to document items such as medication administration, intake and output (I&O), sedation scale, and falls risk assessment.INSERT WHERE STUDENTS FIND FILESLO 6.4 MAR (Medication Administration Record)Legal consideration:Nurses responsible for their own actionsMedication orders that are not consistent with prescribing guidelines should be clarified before administration Nurses have the right to refuse to administer a medication if the orders are not clear or consistent with prescribing guidelinesLO 6.4 MAR (Medication Administration Record)Elements included in MARDrug nameDrug dosageDrug routeFrequency of administrationAdministration timesLO 6.4 MAR (Medication Administration Record)Holding medicationsDocument reason medication not given per facility policyNotify licensed practitioner who ordered the medicationLO 6.5 I&O (INTAKE AND OUTPUT)6.5 I&O (Intake and Output)IntakeAll fluidsOralParenteral, including blood products and medsOutputAll fluidsUrineEmesisDrainage tubes