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Chapter 4 - Nurse note documentation, level 2. After completing Chapter 6, the students will be able to: Use NANDA-International (NANDA-I) approved nursing diagnoses to reflect patient needs, identify patient specific goals using Nursing Outcomes Classification (NOC), identify and document nursing interventions using Nursing Intervention Classification (NIC), carry out documentation of medication administration, carry out documentation of intake and output (I&O).
6-1 Chapter Nurse Note Documentation Level McGrawHill © 2012 The McGrawHill Companies, Inc. All rights reserved 6-2 Chapter Content LO 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) 6-3 LO 6.1 DX (NURSING DIAGNOSIS) 6-4 LO 6.1 Dx (Nursing Diagnosis) • Standardized language – Mechanism for communication – Reflects nursing practice – Facilitates use of technology – Allows comparison of nursing activities – Used in research – Promotes quality patient care – 12 systems recognized by ANA 6-5 LO 6.1 Dx (Nursing Diagnosis) • NANDA-I nursing dx, NOC, NIC – Widely recognized – Research based – Comprehensive 6-6 LO 6.1 Dx (Nursing Diagnosis) • Nursing process – Assessment/diagnosis – Planning – Intervention – Evaluation 6-7 LO 6.1 Dx (Nursing Diagnosis) • Assessment – First step in nursing process – Subjective data • Report of patient and/or family – Objective data • Observations of nurse – – – – Observation Auscultation Palpation Smell 6-8 LO 6.1 Dx (Nursing Diagnosis) • Assessment data used to formulate nursing dx • Nursing 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 illness • Medical diagnosis – Disease process 6-9 LO 6.1 Dx (Nursing Diagnosis) • Nursing diagnosis – Prioritized • High priority = Airway, Breathing, Circulation (ABCs) • Mid priority = threat to health or ability to cope • Low priority = delayed intervention will not cause harm 6-10 LO 6.1 Dx (Nursing Diagnosis) • To assign nursing dx – Collect subjective and objective data – Analyze data to identify actual and potential problems – Assign nursing dx – Individualize nursing dx • Etiology (related to) • Signs & symptoms (as evidenced by) – Place in order of priority 6-11 LO 6.1 Dx (Nursing Diagnosis) • Research evidence – Use of nursing diagnoses improves documentation of assessments – Inclusion of etiology in nursing dx improves both interventions and outcomes – Muller-Staub, M (2009) “Evaluation of the implementation of nursing diagnoses, outcomes and interventions.” International Journal of Nursing Terminologies and Classifications, 20(1), 9–15 6-12 LO 6.2 NOC (NURSING OUTCOMES) 6-13 LO 6.2 NOC (Nursing Outcomes) • Planning phase of nursing process – Determine desired patient outcomes • Short term goals • Long term goals – Individualize for the patient 6-14 LO 6.3 NIC (NURSING INTERVENTIONS) 6-15 LO 6.3 NIC (Nursing Interventions) • Nursing interventions – Nursing actions to help patient achieve goals • Facilitate wellness • Facilitate movement toward wellness – Individualized for patient 6-16 LO 6.4 MAR (MEDICATION ADMINISTRATION RECORD) 6-17 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 FILES 6-18 LO 6.4 MAR (Medication Administration Record) • Legal consideration: – Nurses responsible for their own actions – Medication 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 guidelines 6-19 LO 6.4 MAR (Medication Administration Record) • Elements included in MAR – Drug name – Drug dosage – Drug route – Frequency of administration – Administration times 6-20 LO 6.4 MAR (Medication Administration Record) • Holding medications – Document reason medication not given per facility policy – Notify licensed practitioner who ordered the medication 6-21 LO 6.5 I&O (INTAKE AND OUTPUT) 6-22 6.5 I&O (Intake and Output) • Intake – All fluids • Oral • Parenteral, including blood products and meds • Output – All fluids • Urine • Emesis • Drainage tubes .. . 6- 2 Chapter Content LO 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... Comprehensive 6- 6 LO 6. 1 Dx (Nursing Diagnosis) • Nursing process – Assessment/diagnosis – Planning – Intervention – Evaluation 6- 7 LO 6. 1 Dx (Nursing Diagnosis) • Assessment – First step in nursing. .. implementation of nursing diagnoses, outcomes and interventions.” International Journal of Nursing Terminologies and Classifications, 20(1), 9–15 6- 12 LO 6. 2 NOC (NURSING OUTCOMES) 6- 13 LO 6. 2 NOC (Nursing