Fdar - Dmc Final

Focus charting is a type of documentation that is based on the nursing process of assessment, planning, implementation and evaluation to concentrate on a particular issue and address it. The Data, Action and Response approach (DAR) is used in this method of charting and is meant to keep the information concise. Charting is an integral part of nursing. Nurses are responsible for documenting all care and changes in the patient's condition.

Quality Nursing

care Vision of FDAR

Quality of Records

DOCUMENTATION

Is the process of recording information in the medical chart to support the original written work.

Documentation begins when the patient enters the health care system ( Hospital)

ER

Medical Chart it is the confidential document that contains

detailed and comprehensive information on the individual patient and their care experience.

Purpose: to serve as both medical and legal record of patient

clinical status, care, history, and care giver involvement.

Generally, physicians and nurses write most in the patient’s chart. The documentation by the clinician (physician) often focuses on diagnosis and prognosis based on their physical assessment and history taking, while documentation by the nursing team generally, focuses on patient responses to treatment and details of day to day progress.

In many institutions, the medical and nursing staff may complete separate forms or areas of the chart specific to their disciplines.

the training of our minds obedience to the

rules and character

Another reason for the standard of clear documentation is the possibility of the legal use of the record. When medical care is being referred to or questioned by the legal system, the chart contents are frequently cited in court. For all of these purposes, certain practices that protect the integrity of the chart and provide essential information are recommended for adding information and maintaining the chart.

These practices include: Date and time on all records.Full patient name and other identifiers (i.e.,

medical record number, date of birth) on all records.

Mark continued records clearly (i.e., if note continued on reverse of page).

Sign each page of documentationUse black, blue, and red non-erasable ink on

hand written recordsKeep records in chronological order.Prevent disposal or obliteration of any records.Note documentation errors and correct clearly,

i.e., by drawing one line through the error and noting presence of error or mistaken entry, initialling the area.

Do not alter a patient’s record.Do not chart ahead of time.Do not chart a symptom such as without pain.

Avoid excess empty space on the page.Avoid abbreviations, use only universally

accepted abbreviations. And avoid the use of arrows / signs or ( - ) ( + )

Avoid other unclear documentation, such as illegible penmanship.

Avoid including contradictory information. For example, if a nurse documents that a patient has complained of abdominal pain throughout the shift, while the physician documents that the patient is free of pain, these discrepancies should be discussed and clarified.

Provide objective rather than subjective information. Do not chart what someone else said, heard, felt, or smelled unless information is critical. For example, do not allow personality conflicts between staff to enter into the notes. All events involving the patient should be described as objectively as possible.

Document any occurrence that might affect the patient. Only documented information is considered credible in court. Undocumented information is considered questionable since there is no written record of its occurrence.

Always use current date and time with documentation. For example, if adding a note after the fact, it can be labelled "addendum to care" and inserted in correct chronological order, rather than trying to insert the information on the date of the actual occurrence.

Record actual statements of patients or other individuals in quotes. (“ “)

Never leave the chart in an unprotected environment where unauthorized individuals may read or alter the contents.

If the patient will transfer to another institution do not allow someone else to bring the medical chart or transfer the patient with the chart.

Additional Do’s and Don’ts of DocumentationDo read what other providers have written

before providing care and before charting.Do use flow sheets/ checklist to keep

information on patient’s chart.Do write your own observations and sign over

printed name . Sign and initial every entry.Do use only approved abbreviations.Do use standard chart form.

Don'tsDon’t begin charting until you check the

name and identify the number on patient chart on each page.

Don’t “white out “or erase error.Don’t squeeze in a missed entry or “leave

space” for someone who forgot to chart.Don’t write in a margin.Don’t use notebook , paper or pencil.

OBSOLETE TERMS SUGGESTED PHRASEVital signs taken Document if you were not

able to take vital signs and why.

Afebrile If the patient is febrile, support it with subjective and objective cues. Evaluate effectiveness of nursing intervention of fever, include the element of time.

Due meds/medication given Document the medicines not given and its reason. Document stat medicines given, its indication and evaluate the effectiveness.

Seen at intervals Visit patient frequently and assess for any complication.

Conscious & coherent Patient oriented to date, time and place.

Needs attended/kept comfortable/kept safe

Enumerate measures done to make patient comfortable; verbalized needs must be also documented and referred to Doctors as necessary.

No complaints made/for further management

Why document something that never happened?

No pain Note pain level and then evaluate patient’s response to interventions done

Slept fairly/sleep well/asleep the whole shift

If the patient has difficulty in sleeping, document the subjective cues, interventions done and evaluation*“Slept for approximately 5 hours” as verbalized by patient.

Walking ad lib Walks around the unit, up to the elevator and back to room without any discomfort.

Diuresing well Furosemide 10mg at 2:30pm resulted in 1000ml of clear, yellow urine.

D/C Use “discharge” or “discontinue”.

OD, OS, OU Use “right eye” , “left eye”, “each eye”.

AD, AS, AU Use “right ear” , “left ear”, “each ear”.

U Write “unit”

O.D., QD, o.d., qd Write “daily”

> (greater than) < (lesser than)

Write “greater than”, “lesser than”

cc Write “ml” or “milliliters”

S.O. This is not an accepted abbreviation.

MGH Not an accepted abbreviation. “Patient seen by Dr. Realiza with discharge order given.”

How should information be documented?

Clearly with correct spellingComprehensivelyCompletelyAccurately

How to do Focus Charting or F-DAR

http://nurseslabs.com/wp-content/uploads/2010/05/Focus-Charting-HowTo.jpg

Three columns usually used in Focus Charting for documentation: Date and Hour, Focus, and Progress

Notes. The progress notes are organized into (D)

data, (A) action, and (R) response, referred to as DAR (third column).

DATE/ TimeShift

FOCUS PROGRESS NOTES

7/5/2011 8:00pm 7-3 Shift

Focus of care, this may be:

a nursing diagnosis

a sign or a symptom

an acute change in the condition

behavior

DATA-

ACTION-

RESPONSE-

(Focus ) Nursing Diagnosis:

Hypothermia Insomnia Hyperthermia Hopelessness Diarrhea Risk for nutrition

imbalance Risk for falls Risk for infection Fatigue Risk for suicide Fear Post trauma syndrome Risk for poisoning Oral mucous membrane ,

impaired Ineffective breathing pattern Risk for fluid volume imbalance Risk for fluid vol.excess Risk for injury

(Focus ) Signs and Symptoms:

Abdominal pain, generalized Pain upon urination Epigastric pain Persistent cough Hypogastric pain Indigestion Abnormal vaginal discharges Skin rashes Backache Excessive thirst Headache Swelling Bloody urine Vomiting Difficulty of breathing Numbness Frequent urination Seizures Difficulty in swallowing Tremors Nausea Restlessness

(Focus)Acute change in the condition:

Lack of appetite, nausea, vomitingDizziness or light headednessInsomniaShortness of breathNosebleedPersistent rapid pulseGeneral malaisePeripheral edema (hands , feet, face )Gradual loss of consciousness

(Focus ) Behaviour:

Feeling tired or slowed downRestlessIrritabilitySuicidal attemptLaughingCryingTalking very fast Fear Unable to sleep / little sleep

The Data Category The data category is like the assessment phase

of the nursing process. It is in this category that you would be writing your assessment cues like: vital signs, behaviors, and other observations noticed from the patient. Both subjective and objective data are recorded in the data category.

Ward Setting:Subjective Objective Hooked

vital signs

Example Data: (Ward)D- “ Galisod ko ug ginhawa”, as verbalized by the

patient. Flaring of nostrils noted, gasping for breath, bluish discolo -ration of lips and nail beds, restless. With IVF of D5water 1 liter + 2 amps Anhydrous Theophylline regulated at 15gtts./min. at right metacarpal vein infusing well, with O2 inhalation at 4-5L /min.via nasal cannula, FBC fr. 16 attached to urobag with urine output of 100ml. dark yellow in color. Bp-150/90, HR-100 beats/min., RR- 30 cycles/min.,T.- 38°c .

Subjective Objective Hooked vital

signs

Example Data: ( ER ) ER ( upon admission) : Subjective Objective Vital signs

D- “Sakit akong tiyan”, as verbalized by the patient. Pale,with grimace face, cold clammy skin , restless, with pain

scale of6 out of 10. Bp-140/90, HR- 90beats /min., RR-21

cycles/min. T- 37°c.

The Action CategoryThe action category reflects the planning and

implementation phase of the nursing process and includes immediate and future nursing actions. This may include calling the doctor, giving of STAT medication ( pain relie -ver , antipyretic ),insertion of intravenous fluids, insertion of foley bag catheters, nasogastric tube, endotracheal tube, the making of lab request (CBC, Xray, CT Scan, Request for OR),dressing of wounds, referrals (consultant, anesthesiologist or social worker), positioning of patient, or patient education DR. BLUE,CPR.

An example of the action for a focus of alteration in comfort related to pain might

be:

Assessing pain every two hours, administering pain medication every four hours as needed and repositioning the patient every hour.

The Response CategoryThe response category reflects the evaluation

phase of the nursing process and describes the client’s response to any nursing and medical care.

Example: “ Nawala na ang sakit sa akong tiyan,”as verbalized by the patient. Bp- 120 /80.

Or “Dili nako init maam,” T- 37°C. Or Fever subsided from 39.5˚C to 37.9 ̊C.For follow-up CBC result (ultrasound result, xray

result, or CT scan result)

NURSING DOCUMENTATION FOR QUALITY NURSING CARE

“THE QUALITY OF INFORMATION IS TOTALLY DEPENDENT ON THE QUALITY OF RECORDS CREATED AND MAINTAINED BY PEOPLE

INVOLVED”

“WHAT ARE THE PRINCIPLES OF DOCUMENTATION”

DOCUMENTATION…

Should be SYSTEMATIC, TIMELY, and ACCURATE and give a CLEAR ACCOUNT of the nursing care that was provided.

Should contain COMPLETE and ACCURATE set of INFORMATION to facilitate effective Patient Care and its Evaluation.

HOW DO WE DETERMINE COMPLETENESS OF RECORDS?

It is ACCURATE if what is recorded conforms very closely to the true condition of activities performed.

Records should be adequate if it sufficiently shows compliance with acceptable standards. Entries should be up-to-date to be reliable.

WHAT ARE THE FUNDAMENTALS OF EFFECTIVE DOCUMENTATION?

Effective Documentation means…

A. Write legibly, neatly, clearly and readably.

B. Use proper spelling and grammar. Misspelled words and wrong use of grammar could lead to misinterpretation of entries.

C. Choose terms carefully, be specific and concise. Use of appropriate terms to describe patient’s condition.

D. Write the date and time of each entry.- Documenting the sequence of events and changes in patient’s condition is essential; document as soon as possible after an observation is made and when care is provided.

• Use only approved abbreviations as these can lead to serious errors.

F. Document all observations objectively.- Complete factual accurate decision will give a clear account on patient’s care.

G. Correct errors by drawing a single line and place above the line “mistaken entry”, then sign above the mistaken entry.

H. Sign all documents. Always PRINT your complete name and affix your signature, if possible use tro dat.

DATE/SHIFT/TIME

Sample 1

FOCUS DATA ACTION RESPONSE

08/24/2011 7-3 shift

9:00 AM

9:10 AM

10:00 AM

Abdominal Pain

D-Patient verbalized “sakit gyod akong tiyan”, pain scale 8 out of 10, facial grimacing, guarding behavior, irritable, Temperature 37.40C, pulse 70 beats per minute, respiration 18 breaths per minute.----------A-Administered Hyoscine N-butyl bromide 20 mg Intravenously as per doctor’s order, encouraged and demonstrated deep breathing exercises, placed in semi Fowlers position with side rails up and locked.R-Patient reports pain was relieved. Pain scale 5/10.-------------------------------------------Lysette Bagatua,RN

DATE/SHIFT/TIME

Sample 2


08/24/20117-3 shift

1:00 PM

1:05 PM

2:00 PM

Elevated Body

Temperature

D-“Init akong lawas” as verbalized. With flushed skin and warm to touch, Temperature 38. 90C via axilla, pulse 80 beats per minute, respiration 24 breaths per minute, blood pressure 120/80.-----------------A-Performed tepid sponge bath, applied ice cap on forehead, administered Paracetamol 250mg intravenously as per doctor’s order. Encouraged adequate oral fluids intake, provided calm environment to keep patient comfortable.---------R-“Gipaningot na ko”, as verbalized, temperature decreased to 37.20C.----------------Lysette Bagatua,RN

DATE/SHIFT/TIME

Sample 3


09/15/087-3 shift

9:00 AM

9:10 AM

9:20 AM

Pain at IV Site

D-”Sakit man ang lugar nga naa ang dextrose” as verbalized IV site slightly swollen and with redness noted.----------A- Checked IV site and found beginning of signs of infiltration. Closed and removed IV aseptically, changed the whole system, reinserted the new set aseptically into the distal portion of basilic vein, left arm anchored, splint applied, regulated IVF as to the prescribed drops. Advised to call nurse for any presence of pain.-----------------------R-“Wala na ang sakit sa akong dextrose”,as verbalized---------------------------------------------------------------M. Omamalin,RN

DATE/SHIFT/TIME

Sample 4


08/25/11 7-3 shift

9:10 AM

9:15 AM

ER to ORPre-

Operative Assessment

D-Received from ER per stretcher with side rails up and locked with ongoing IVF of PLR 1L. at 900ml level at left cephalic vein using IV cannula gauge 18 regulated at 30 drops/min., with oxygen inhalation at 3L/min. via nasal cannula, nasogastric tube attached to drainage open bottle with bloody discharges noted, Foley Bag Catheter connected to urobag with 100ml of tea colored urinary output. Cold clammy skin, grimace face, gnawing abdominal pain noted.A-Instructed patient to do deep breathing exercise. Checked the patency of IVF drop factor, name of patient and IVF hooked, checked the nasogastric tube and Foley Bag Catheter if dripping well. Reviewed and checked the patient chart if all laboratory results were attached, surgery consent signed and availability of surgical materials and pre operative medicines. Checked and reviewed Operating Room checklist, jewelries, dentures, nail beds, name tag of patient applied. All surgical and pre operative medicines checked. BP checked 100/60, HR 92 beats/min. Respiratory rate 21 breaths/min. Skin cleaned. ------------------------------------------------------------

DATE/SHIFT/TIME


9:20 AM

9:30 AM

9:35 AM

9:45 AM10:00 AM

1:20 PM

1:35 PM

For surgical procedure (explor lap)

-Transported per stretcher side rails up and locked accompanied by circulating nurse to Operating Room table.-------------------A-Placed comfortably on Operating Room table on supine position both arms strapped; orientation done on Operating Room procedures, and validated all entries in the WHO Surgical Safety Checklist.-------------------------------------------------------------------Skin preparation done aseptically and applied sterile drapes to abdominal area. Surgical instruments, needles, sponges counted and witnessed by circulating nurse, J. Lopez.----------------------General anesthesia induced by Dr. Evangeline S. Ruaya.------Exploratory Laparotomy performed by Dr. G.Realiza with Dr. C. Mata as Surgeon’s Assistant.-----------------------------------------Surgical operation ended. All surgical instruments and supplies are accounted and declared complete. Nasogastric tube attached to drainage bottle and Foley Bag Catheter attached to urobag draining well. ----------------------------------------------------------------------Dressing done aseptically on post operative site . Arm straps removed.-------------------------------------------------------------

1:40 PM -R-Responsive to stimuli and pain, with spontaneous eye opening, BP-checked 100/60, HR-90bpm, RR-20bpm with IVF of PLR 1L ongoing regulated at 30 drops left cephalic vein, another line PNSS 1L. at 20 drops right metacarpal vein infusing well. Accompanied and transported to PACU per stretcher, side rails up and locked. Endorsed to nurse K. Eguia.-----------------------------Grace Bengua,RN

DATE/SHIFT/TIME


PACU 1:45 PM

1:50 PM

1:55 PM

D-Received patient from Operating Room per stretcher, side rails up and locked, with on-going IVF of PLR 1L. at 200 cc level at left cephalic vein at 30 drops infusing well, another line of PNSS 1L. at 500cc level and regulated at 200 drops/ min with nasogastric tube attached to open drainage bottle open to drain with bloody discharges Foley Bag Catheter connected to urobag with 200cc of tea colored urinary output; with oxygen administered at 3L/min via nasal cannula.----------------------------------------------------------------------Skin cold to touch, pale looking, chilling sensation noted.----A-placed comfortably on bed with side rails up and locked; oxygen administered continuously at 3L/min.; monitored blood pressure every 15 mins. Warm blanket applied. Hot water bag cap locked tightly applied to both upper and lower extremities post-operative; wound checked for bleeding. Measured and recorded intake and output. Administered Tramadol 30mg injected very slowly thru IVTT as per Doctor’s order. Administered antibiotics initially after negative skin test done as post operative order by the Doctor. Ceftriaxone 1gm administered slowly thru IVTT. Observed for adverse reaction of the drug. Observed for nausea and vomiting.---------------------

DATE/SHIFT/TIME


PACU3:35 PM

3:40PM

4:00 PM

4:15 PM

Dr. Evangeline S. Ruaya updated for patient status, BP checked 110/70, HR 92 bpm, RR 21 bpm, T- 36.50C, thru text with reply “may transport to ward”-------------------------------------------------R-“Dili na kaayo sakit akong samad, Mam” as verbalized by the patient. Able to move both upper and lower extremities post-operative wound checked for bleeding; sterile dressing intact and dry as observed.---------------------------------------------------------A-Transported to Surgical Service, per stretcher, side rails up and locked.--------------------------------------------------------------------------Endorsed to Surgical Service Ward Nurse on duty.----Kate Eguia,RN

DATE/SHIFT/TIME

Sample 5


8/24/20113-11 shift

9:15 PM

9:25 PM

9:50 PM

10:00 PM

Altered comfort

related to post-

operative pain

D-“Sakit akong samad sa tiyan, Sir” as verbalized.-----------------Facial grimace noted, irritable, moaning noted, pain scale of 8/10, received from PACU via stretcher with ongoing venoclysis of PLR 1L. with 900ml level left hooked at right cephalic vein, with nasogastric tube in place open to drain with greenish output; and indwelling catheter in place attached to urine bag with output of 450ml yellow tinged urine.---------------------------------------------------------A-Placed on bed in supine position, medication record checked for last administration of Tramadol; instructed to do deep breathing; supported abdomen with pillow while turning to sides, abdominal binder applied----------------------------------------------------------------R-“Sakit pa gihapon akong samad” as verbalized. Still in pain as evidenced by a pain scale of 7/10. ------------------------------------A-Inspected dressing for discharges. Dressing dry and intact. Given with Tramadol 50mg as PRN for pain intravenously, with blood pressure precaution.--------------------------------------------------------

DATE/SHIFT/TIME

Sample 5


10:35 PM R-“Arang-arang na akong pamati, Sir” as verbalized, pain has reduced as evidenced by a pain scale of 4/10. Patient understood instructions and seen performing deep breathing. Endorsed to 11-7 shift for continuity of care.------------------------------------M. Galvez,RN

DATE/SHIFT/TIME

Sample 6


08/23/20117-3 shift

7:00 AM

7:30 AM

7:35 AM

8:00 AM

Altered comfort:

Pain related to post

Caesarean Section wound

D-Received on bed with on-going intravenous fluid of D5LR 1 liter at 550ml level infusing well on right cephalic vein at 20gtts/min-----------------------------------------------------------“Sakit akong samad”, as verbalized. With pain scale of 8/10 BP of 130/100, pulse 105 b/min., T-37.30C; restless, guarding behavior over incision site, facial grimace, profuse sweating, pale looking.---------------------------------------------------------A-Incision site checked with no foul smell and no discharges; wound dressing intact and dry; repositioned to Semi-Fowlers position. Encouraged and demonstrated relaxation techniques such as deep breathing. Applied abdominal binder.-----------------------------------------------------------------R-“Sakit pa gihapon akong samad” as verbalized; pain scale of 7/10, BP 130/90------------------------------------David Silva,RN

DATE/SHIFT/TIME

Sample 7


08/23/20113-11 shift

3:00 PM 4:00 PM

4:20 PM

4:45 PM4:50 PM

5:00 PM

Anxiety related to scheduled

surgery

D-Received with IVF of D5LR 50ml at KVO at left cephalic vein.---“Mahadlok ko sa operasyon nako unya”, as verbalized. Asked questions repeatedly regarding surgery. Cold, clammy skin, looks worried, pale-looking. BP-150/90, HR-128 b/min, RR-24 c/min, T-360C.-------------------------------------------------------------------------A-Family members encouraged to stay with the patient. Referred to Dr. Lee for the re-explanation of the surgical procedure. Encouraged to verbalize feelings. Consent signed by the patient Assisted Dr. Lee during rounds. Procurement of materials for surgery followed-up. Provided perioperative health teachings. Allowed to ask questions and answers provided.-------------------R-“Nakasabot na ko sa operasyon. Wala na ko nahadlok. Gipapalit na nako ang mga gamit sa operasyon” as verbalized. Appears relaxed and skin is warm to touch. T-36.50C, RR- 18 cpm, HR-89 bpm, BP-120/90, -------------------------------------------------Ira Lakian,RN

DATE/SHIFT/TIME

Sample 8


8/25/20117-3 shift

6:50 AM

6:55 AM

6:57 AM

Abdominal pain Scale

of 9/10

D-“Nadisgrasya siya Maam, gasakit iyang tiyan” as verbalized by wife. Brought in per stretcher, pale and cold clammy skin noted, in severe pain scale of 9/10, in moderate respiratory distress bluish contusion 6cm observed at the right temporo-parietal and in the left parietal areas. Abdominal pain noted as evidenced by grimaced face, with a board-like abdomen on palpation, slightly restless, GCS 15/15, T-360C P-110 beats/min R-42 breaths/min BP-50/30.-----Placed on bed with side rails up and locked, with head of bed elevated to 300 angle, 02 inhalation administered at 3-4 L/min via nasal cannula. Ice pack applied to contusions. ----------------------Seen and examined by Dr. Genesis Realiza, consent for admission signed by wife. Started with venoclysis of PLR 1L at fast drip for the first 500ml hooked at the left cephalic vein using IV cannula gauge 18, then regulated to 60 gtts/min. Another line initiated at the right metacarpal vein with PLNSS 1L using blood transfusion set regulated at 15gtts/min.-------------------------------------------------

DATE/SHIFT/TIME


7:00 AM

7:30 AM

7:50 AM

R-BP rechecked 80/40 P-120 beats/min R-44 breaths/min, “sakit kayo akong tiyan Maam”, as verbalized .--------------------------------A-Ketorolac 30mg IVTT given as ordered stat. Brought to the X-ray and accompanied by nurse M. Omamalin per stretcher with side rails up and locked for abdominal x-ray flat plate and upright view; stat CBC, BT taken by Medical Technologist Antonio Lagod. -------X-ray plates and CBC results seen by Dr. Realiza, orders given. Scheduled for an emergency exploratory laparotomy, consent for surgery and induction of anesthesia signed by wife, after proper explanation of pre-operative and post-operative procedure done by Dr. Realiza. Nasogastric tube Fr.16 inserted at the right nostril by Dr. Realiza and open to drain; Foley Bag Catheter Fr.16 inserted aseptically by nurse M. Omamalin and attached to urobag with tea colored urine output at 150ml level. Instructed the wife to secure 2 “units” of blood of patient’s blood type “A+” for possible surgical operative use. OR nurse Mr. Mark Galvez and anesthesiologist Dr. Evangeline Ruaya informed of the procedure. ------------------------

DATE/SHIFT/TIME


8:20 AM

8:55 AM

9:15 AM

Cefuroxime 1.5gm administered as loading dose via IVTT after a negative skin test and no adverse drug reaction noted after 30 minutes.-------------------------------------------------------------------------R- Prescribed drugs and surgical supplies already available. Still with abdominal pain, scale of 8/10, moderate bloody discharges in NGT, T-36.80C, PR-12 beats/m, RR-40 breaths/min, BP-90/60---A- Transported to OR per stretcher with side rails up and locked and complete drugs and surgical supplies needed.----------Nesle Lim, RN

DATE/SHIFT/TIME

Sample 9


7/23/2011 7-3 shift

10:00 AM

10:15 AM

11:00 AM

Constipation D-“Maam, tulo na kaadlaw wala ko nakalibang” as verbalized.Stomach distended, hypoactive bowel sound upon auscultation noted; irritable, T-7.80C, PR-80 bpm, RR-28 bpm BP-130/90.----A-Given suppository per Doctor’s order and provided privacy; advised to increase fluid intake and eat foods high in fiber like green leafy vegetables (kangkong, pechay, malunggay) and fruits (papaya, pineapple), encouraged mobility------------------------------R- Able to defecate and felt comfortable.------------------Belia Bohol,RN

DATE/SHIFT/TIME

Sample 10


8/23/20113-11 shift

3:05 PM

3:10 PM

3:15 PM

6:00 PM

11:00 PM

Ineffective air way

clearance related to excessive mucous

secretions

D-“Naglisod ko og ginhawa” as verbalized, with labored breathing, productive cough with mucopurulent seceretions, RR-30 bpm, with slight flaring of nostrils-----------------------------------------------------A-Lowered the bed, placed on high Fowler’s position with side rails up and locked; administered Oxygen at 3 liters per minute; loosened clothing and made comfortable------------------------------Referred to Dr. Maurice Montecillo. Orders given; nebulized with 1 nebule as ordered; PLR 1L started at 15gtts/min at right metacarpal vein infusing well; demonstrated back tapping after nebulization, encouraged and demonstrated deep breathing and coughing exercises, encouraged increase oral fluids intake to 8-10 glasses per day; provided a calm and well ventilated environment free from allergen.-----------------------------------------------------------R-Verbalized ease of breathing and tolerable cough. Understanding of instructions noted through demonstration of proper deep breathing and coughing exercises. ---------------------------------------Latest RR-24 cycles/min and endorsed to next shift.---Peter Soro,RN

DATE/SHIFT/TIME

Sample 11


8/25/2011 7-3 shift

11:50AM

12:00 Noon

12:05 PM

12:15 PM

Elevated blood

pressure

Admitted this 52 y.o. female with complaints of body malaise and numbness at left side of the body with onset of headache prior to admission.---------------------------------------------------------------------D- “Lain iyang pamati”, bas verbalized by the daughter, Maria Realiza. Patient is lethargic with facial drooping noted, with slurred speech, with initial vital signs of BP 180/100, HR-132 bpm T-37.20C per axilla.------------------------------------------------------------------------A-Ushered to ER bed and positioned to semi-Fowler, side rails up and locked, initiated with humidified oxygen support at 3-4 liters per minute via nasal cannula. Consent to care signed by the daughter, Maria Realiza, Referred to resident on duty Dr. Lucy Itok about this admission---------------------------------------------------------Assisted Dr. Itok on her bedside assessment. Orders made and carried out properly. Plain NSS 1L inserted aseptically as venoclysis at 20 gtts/minute at left metacarpal vein; Captopril 25mg. given sublingual (not to chew nor crush the tablets) Furosemide 40mg. given intravenously STAT. All are as ordered. -------------------------

DATE/SHIFT/TIME


12:25 PM

12:30 PM

2:00 PM

-CBC, BUN, CREA, Lipid Profile, FBS requests sent to laboratory. EKG taken and referred to Dr. Itok for interpretation----------------------Informed the watcher about ICU admission. Consent for ICU admission signed by daughter, Maria Realiza. ICU informed about this admission. Request for Plain Brain CT Scan and chest X-Ray AP view handed over to watcher for payment at Cashier’s Office. Referred to neurosurgeon, Dr. Jones for evaluation and management thru phone call and responded “will see the patient later”. CT Scan and Chest X-Ray taken as accompanied by ER Nurse, Mark Galvez, and transported to ICU per stretcher with side rails up and locked.-----------------------------------------------------------Endorsed to ICU Nurse on duty, Rhoda Ordinaria.----------------------------------------------------------------------------------------Gerry Zamoras,RN

DATE/SHIFT/TIME

Sample 12


8/25/20113-11 shift

3:00 PM

3:10 PM

4:00 PM

Elevated Blood

Pressure 160/90

D-Appears lethargic , cold and clammy skin noted, flaccid muscle tone on the left side of the body; right facial drooping noted, slurred speech, able to move all extremities per command but with left hemiparesis; eye opening is appreciated upon name calling; anisocoric, pupillary size of 6mm at right eye and 3-4mm at left eye; right pupil is sluggishly reactive to light while left pupil is briskly reactive to light accommodation. BP-160/90, HR-98 bpm, RR-23 cpm, T-370C.--------------------------------------------------------A-Placed on bed with side rails up and locked; head of bed elevated at 300 angle; oxygen inhalation administered; hooked to cardiac monitor and pulse oximeter attached; visited by Medtech for blood extraction, CBC, BUN, CREA.---------------------------------Visited by Dr. Jones. Orders given and carried out properly. Serum Na+ and K+ determination request sent to laboratory; 3-way urinary catheter Fr.16 inserted aseptically and obtained urine specimen and brought to laboratory for urinalysis then catheter attached to urine bag.---------------------------------------------------------------------

DATE/SHIFT/TIME


4:15 PM

5:15 PM

6:30 PM9:30 PM

10:30 PM

-Mannitol 20% 500ml given 150ml at fast drip using large bore needle gauge 19; Nicardipine in 80ml of D5Water via soluset at initial rate of 100 microdrips per minute and titrated by increments of 5 microdrips per minute every 15 minutes to maintain systolic BP range of 120-150 as ordered. Arterial blood specimen extraction done aseptically by Dr. Jones and sent to laboratory.-------------Laboratory results for CBC, S CREA, BUN and ABG in. Relayed to Dr. Jones thru SMS, updated patient’s status and replied “ok thanks”---R-BP rechecked 140/80.---------------------------------------------------A-Visited patient and encouraged verbalization of any medical problems such as headache. Continuous BP monitoring done.R-Last BP 140/80 for FBS and lipid profile determination in AM. Endorsed to next shift Nurse J. Bataga.------------Rhoda Ordinaria,RN

DATE/SHIFT/TIME


8/25/201111-7 shift

11:00 PM

12:00 MN

D-Received on bed awake with head of bed at 300 angle elevation, with ongoing IVF of PNSS 1L hooked at left metacarpal vein flowing at 20 drops/min infusing well, with 160ml level left with starting dose of Nicardipine Drip (80ml D5W + 20mg) at 10 microdrips/min. rate. With ongoing humidified 02 inhalation at 3-4 l/min. via nasal cannula, with indwelling urinary catheter attached to urine bag, patent and draining well; contains bright yellow urine with approximately 150ml in volume. With multiparameter cardiac monitor attachment, right facial area drooped. As noted, with pupillary size of right eye 5-6mm, left eye 3-4mm, right pupil is sluggishly reactive to light, while left pupil is briskly reactive to light accommodation, able to move all extremities per command, slurred speech, with spontaneous eye opening. -------------------D-“Labad man akong ulo Ma’am” as verbalized while pointing at right parietal area of the head, facial grimace is noted, irritable with pain scale of 7/10; BP 160/100, HR-119bpm, RR-24cpm, T-37.30C, 02 sat 97%.---------------------------------------------------------

DATE/SHIFT/TIME


12:10 AM12:13 AM12:15 AM

2:00 AM

3:00 AM6:45 AM

A-Dim light provided, applied ice pack over the right parietal area.---Referred to Dr. Jones thru phone call, orders made and carried out properly. STAT dose of Tramadol 25mg given slow IV as ordered, STAT dose of Mannitol 20% 100ml given via IV fast drip as ordered. Unnecessary disturbance avoided and promoted a cool, calm and quite non stimulating environment.----------------------------------R-“Nawala-wala na ang labad sa akong ulo Maam” as verbalized by patient, pain scale of 4/10. -----------------------------------------------A-Seen soundly asleep and undisturbed.-----------------------------R-Verbalized to be free from pain; Still for lipid profile and FBS determination.------------------------------------------Rhoda Ordinaria,RN

DATE/SHIFT/TIME


8/26/20117-3 shift

7:30 AM

7:45 AM

7:50 AM

7:55 AM

D-Received on bed in supine position at 300 angle head of bed elevation. With ongoing IVF of PNSS 1L at 20 drops/min at left metacarpal vein with 520 fluid level left, with side drips of 20ml Nicardipine and 80ml of D5W via soluset at 10 drips/min; with humidified oxygen inhalation at 3-4 liters per minute via nasal cannula with indwelling urinary catheter attached to urine bag with yellow colored urine at approximately 200ml. Appears conscious with spontaneous eye opening and pupillary size of 5mm sluggishly reactive to light at right eye and 3mm briskly reactive to light at left eye, patient show body weakness but able to move all extremities per command, with slurred speech as verbal response. Initial vital signs of BP-130/90, HR-82 bpm, RR-20 cpm, T-36.50C.-----------A-Oatmeal diet was served to the patient and able to consumed 8 spoonfuls of the food. On Aspiration Precaution; assisted patient on sitting position; assisted Dr. Itok during visit with given order of “may transfer to room of choice if okay with Dr. Jones”. Informed Dr. Jones thru telephone with telephone order of “okay for me to transfer to ward”. ----------------------------------------------------------

DATE/SHIFT/TIME


7:40 AM7:48 Am7:52 AM

8:00 AM8:15 AM

8:25 AM

8:28 AM

9:00 AM

9:15 AM

Knowledge deficit

related to disease process, lifestyle

-Visited on bed and encouraged to verbalize feelings. Positioned to semi-fowlers and maintained safety measures by placing side rails up and locked. Informed the daughter regarding the transfer and given options regarding various accommodations. ---------------Family member opted to be accommodated at suite room. Informed station nurse on duty thru phone call on patient’s transfer.------------------------------------------------------------------------D-“Maam, unsa kaayo ang ginadili nakong kan-on?” as asked by patient. Appears confused and worried.------------------------------A-Explained the importance of lifestyle and diet modification and advantages of compliance. Instructed also to avoid taking alcohol and smoking. Encouraged patient to limit intake of high sodium, high fat and high cholesterol diet, instead encouraged increased intake of green leafy vegetables and high fiber diet.---------------R-“Dili nako manigarilyo og mu-inon og beer karon Maam. Ako na pud limitahan akong pagkaon og mga tambok og asgad na pagkaon” as verbalized. Seen patient smiling and comfortable in bed.-----------------------------------------------------------------------------

DATE/SHIFT/TIME


9:28 AM

10:00 AM

11:15 Am

11:23 AM

A-Assisted Dr. Jones during visit. For referral to physical therapist for further management as ordered. Request form sent to rehab unit by the nursing attendant Ms. Nayal. Take home medication was ordered and carried out correctly at discharge instruction sheet.---------------------------------------------------------------------------A-Assisted family member during visiting hour. Health teaching was imparted on the importance of constant monitoring of blood pressure, the compliance of medication and the importance of early consultation for any health care related problems. Take home medications discussed and explained to the patient and the daughter. Reminded also regarding the patient’s next scheduled visit on September 21, 2011 at 8am, OPD.---------------------------R-Patient able to enumerate all take home medications with correct dosage and timing. Patient’s daughter verbalized “Nakasabot nako Maam”-------------------------------------------------A-Received phone call from ward stating that the room is ready for transfer.--------------------------------------------------- Rhoda Ordinaria,RN

DATE/SHIFT/TIME


11:25 AM

11:40 AM

11:57 AM

Pre-assessment

upon patient transfer

D-Awake and responsive, free form any pain, still slurred speech as verbal response, body weakness still noted but able to move all extremities at times without any command. Pretransport vital signs are BP-130/90, HR-76 bpm, RR-18 cardiac per minute, T-370C per axilla.---------------------------------------------------------------------------A-Transported to Suite Room per stretcher with side rails up and locked. Aided throughout the transport.-----------------------------Informed attending physicians Dr. Itok and Dr. Jones that patient was transferred at Suite Room with room number 307 thru phone call.------------------------------------------------------------------------------R-Still awaiting to be seen by Physical Therapist for daily range of motion exercises. Discharge instruction sheet was attached to chart and to be given to the family prior to discharge. Endorsed to nurse on duty.----------------------------------------------------Rhoda Ordinaria,RN

DATE/SHIFT/TIME

Sample 13


8/25/20116-2 shift

6:00 AM

6:05 AM

6:10 AM

7:08 AM

Hemodialysis with

pulmonary congestion

Received from medical ward per wheelchair with 02 inhalation on going at 5-6L/ml via nasal cannula.-------------------------------------D-“Naglisod ko ug ginhawa Ma’am” as verbalized; oriented to place, date and time; labored breathing noted with flaring of nostrils; weight gain of 4.0kgs; BP-150/100; with heplock on right metacarpal vein.-------------------------------------------------------------A-Assisted comfortably to the hemodialysis chair; consent for hemodialysis signed by wife; skin preparation of arteriovenous fistula access done aseptically and with positive thrill upon palpation; cannulated with ease.---------------------------------------Hemodialysis started scheduled for 4 hours with ultrafiltration goal of 4.0 liters and ultrafiltration rate of 250-350 ml/min; 2000 units of regular heparin given as IV bolus and 1000 units every hour thereafter as anticoagulant;monitored for signs of hypotension; BP/HR monitoring done every 15 mins.-------------------------------visited by Dr. G. Doble with order made to discharge patient after hemodialysis once cleared; ward nurse informed of the discharge order to facilitate for the billing and discharge clearance of the patient.-------------------------------------------------------------------------

DATE/SHIFT/TIME


9:00 AM

9:05 AM

10:10 AM

10:40 AM

Health teaching

with discharge

instructions

R-“Puede na ko dili mag-02 Ma’am kay mayo na ang akong ginhawa”, patient verbalized; looks relaxed and normal breathing pattern was observed.-----------------------------------------------------A-Reinforced teaching given to both patient and wife to limit oral fluid intake to 700ml/day to avoid dyspneic attack; instructed to have a low-salt, low fat and low purine diet; reminded patient of saving left arm to prevent potential damage to access site for future use.----------------------------------------------------------------------Encouraged patient to come on his next hemodialysis schedule.R-“Mag-control na ko sa akong imnon ug magbantay na ko kung unsa akong kaunon”, as verbalized by patient HD completed; cannula removed and pressure dressing is applied; heplock removed and dressed; assisted patient to upright position and 5 mins. to prevent orthostatic hypotension. ---------------------------Discharged ambulatory with assistance to vehicle with clearance in fair condition.-----------------------------------------------Prisca Nalzaro,RN

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