Nursing Education, Nursing Schools, Nurse Jobs, Nursing Reviews and News, Nursing Review Centers, Board Exam Results at Nurse Online » Funda http://nurseonline.org Knowledge Sharing For Nurses and Students Mon, 23 Nov 2009 04:09:16 +0000 http://wordpress.org/?v=2.8.6 en hourly 1 Types of Nursing Charting l Patient Progress Notes http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/ http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/#comments Wed, 23 Sep 2009 03:10:00 +0000 Site Admin http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/ Posted by : Rey-Ryan P. Mapiles RN

Types of charting
Regardless of the system of charting you use, it must include the nursing process as a guideline.
1. Assessment
2. Planning
3. Implementation
4. Evaluation

Assessment includes observing the patient for signs and symptoms that may indicate actual or potential problems.
Planning includes developing a plan of care directed at preventing, or resolving identified client problems or issues.
Implementation (or intervention) of the plan that has been developed includes the specific action that the nurse needs to take to accomplish the plan.
Evaluation determines whether or not the goal was met in identifying if the plan of care was effective in preventing, or resolving the problem.

Narrative charting
The nurse documents in chronological order the events that took place throughout the shift. Narrative charting is time consuming, so make certain your notes are legible and clear to understand by all who reads them.

A note should be made at least every two hours.

SOAP Notes
This method is preferred by many nurses. It stands for Subjective data, Objective data, Assessment, and Plan. Sometimes it can be referred to as SOAPIE or SOAPIER, in which the “I” indicates implementation and “E” indicated Evaluation. When an “R” is included, this indicates Revision.

APIE
More commonly known as “Pie Charting”
Assessment, Plan, Intervention (or implementation), and Evaluation. It is more concise in the aspect that the nurse will indicate subjective and objective data in the assessment section, what will be done in the plan, the intervention and the outcome. As it follows through in A, P, I, E format.

Flow Sheets
Also known as graphic sheets, or graphic records. These are a quick way to document. They need to be used CAREFULLY, as some areas do not apply to all patients. Avoid leaving any boxes unmarked, and individualize it to meet your patients needs.

Focus Charting
The term focus was developed to encourage the nurse to view the client’s status from a positive perspective rather than a negative perspective. The system uses three columns to indicate date/time, focus, and progress note.

The progress note portion includes DAR( date, time, response)
Date/time focus progress note
Date:
Action:
Response:

Charting by exception
Also known as CBE. A system of charting in which only significant information, findings, or exceptions are documented.

Nursebitz.com ALERT: No matter which method you prefer, or your facility uses, make sure that the content is addressing the proper do’s and don’ts for charting.

]]> http://nurseonline.org/types-of-nursing-charting-l-patient-progress-notes/feed/ 0 do not’s of charting in Patient’s Medical Record http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/ http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/#comments Wed, 23 Sep 2009 03:03:00 +0000 Site Admin http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/ Posted by: Rey-Ryan P. Mapiles RN

The do not’s of charting are very important also:

1. Don’t chart a symptom such as “c/o Pain” without also writing what you did about it.
2. Don’t alter a chart….this is a criminal offense.
3. Don’t add information at a later date without indicating that you did so.
4. Don’t date the entry so that it appears to have been written at an earlier time.
5. Don’t use shorthand or abbreviations that are not standard.
6. Don’t write vague descriptions such as “ large amount of drainage”
7. Don’t make excuses, such as “meds not given because not available.”
8. Don’t chart what someone else says unless you use quotations and state who said it.
9. Don’t chart an opinion.
10. Don’t use words that suggest a negative attitude, such as “weird” or “nasty”
11. Don’t chart ahead of time. If something happens it will look bad to go back and make that
correction.
12. Misspelled words and bad grammar are as bad as illegible handwriting.
13. Don’t record staffing problems.
14. Don’t document that an incident report was completed.
15. Don’t record staff conflicts.

Charting care that was not given is fraud. It is punishable by the law and can land you in court, or put your license in jeopardy.

Nursebitz.co ALERT: if you make a mistake, draw a line through the error, and indicate it as an error, and then initial it. Do not write “oops” or “sorry” or draw a happy or sad face in the margin, or any where on the document. This is unprofessional and inappropriate. Don’t leave any blank spaces. Never save a space for a colleague who forgot to chart.

]]> http://nurseonline.org/do-not%e2%80%99s-of-charting-in-patients-medical-record/feed/ 0 Nursing Documentation http://nurseonline.org/nursing-documentation/ http://nurseonline.org/nursing-documentation/#comments Wed, 23 Sep 2009 03:00:00 +0000 Site Admin http://nurseonline.org/nursing-documentation/ Posted By by: Rey-Ryan P. Mapiles RN

What Is Documentation?

Documentation means “to give written information that is proof or support of something that has been done or observed.” Documentation is the written account of observations, the information the client, resident or family relates or states, the data you collect during care, and the care that you provide.

A medical record is a collection of information about the person you are caring for. It is a legal and confidential record with pertinent information related to the care provided.

We have heard it said over and over again, “ If you did not document it, it was not done”. We have heard this a thousand times. Lets look at what all this means………….

Simply put, a medical record is the record of all care that is provided. If it is not recorded, it did not happen. If it is recorded incorrectly, it happened incorrectly. This is why it is so important to be accurate when documenting.

Four most commonly used forms with particular importance are:
1. Nurse’s progress notes
2. Graphic sheet for vital signs
3. Care plans
4. Activities of daily living sheets

These are the forms where the most pertinent data is collected. There is little room for error on these documents. This is not to say that the rest of the chart is not equally as important, as the whole record is essential. These forms are particularly important because the content they contain sum up what was done ( or not done ) for the patient.

Legal Implications
Documentation provides crucial legal protection. Admissible in court, the patient’s medical record must be documented in an accurate, complete, systematic, logical, concise, and timely manner. Courts will view the documentation in the medical record as proof and verification to patient care. By showing that the individual under your care received quality, adequate care, a well documented record can, and will most likely protect you legally.

The medical record is a legal document. It is also regarded as highly confidential. In the event of a medical malpractice case, the medical record may be used to provide the court with evidence about a person’s condition and treatments. In a malpractice case, the jurors usually view the medical record as the best evidence of what really happened. For this reason, all documentation should be neatly written and legible. Illegible handwriting is handwriting that cannot be read or understood by others. This would account for sloppy writing, and often misspelled words and poor grammar. Illegible or poorly written documentation makes you look careless and distracted. Take the time to write neatly and clearly. Avoid words that are unnecessary or very long. When you abbreviate, make sure it is a standard abbreviation with no possibility of having more than one meaning.

DO NOT cover up anything in a chart with white out. Draw one line through it and indicate “error”, and be certain you initial it.

Nursebitz.com ALERT: if you didn’t chart it, you didn’t do it… has another meaning, if you did not do it, don’t have someone else chart you did what you did not. Also, do not document care provided by someone else. If there is a problem, you will be held liable.

]]> http://nurseonline.org/nursing-documentation/feed/ 0 Do’s to Good Charting in Patient’s Medical Record http://nurseonline.org/dos-to-good-charting-in-patients-medical-record/ http://nurseonline.org/dos-to-good-charting-in-patients-medical-record/#comments Wed, 23 Sep 2009 02:49:00 +0000 Site Admin http://nurseonline.org/dos-to-good-charting-in-patients-medical-record/ Posted by: Rey-Ryan Mapiles RN

Do’s to good charting
1. Check to be sure you have the correct chart before you begin writing
2. Make sure your documentation reflects the nursing process and your professional capabilities.
3. Write LEGIBLY
4. Use a permanent black ink pen ( other colors do not Xerox well)
5. Chart completely
6. Be concise and accurate
7. Chart time for each entry
8. Document PRN medications and exceptional things in the record.
9. Chart precautions or preventative measures, ( Such as use of side rails)
10. Include the following for procedures: what was done, when it was done, who did it, how it
was done, how the client tolerated it, adverse reactions, if any. Paint a clear picture of what
happens.
11. Record each phone call to or from a physician, including exact time, message, and response.
12. Chart when a doctor makes a visit, and if there are any new orders.
13. Chart as soon as possible after providing care.
14. Chart a client’s refusal of treatment or medications.
15. Chart client’s subjective data.. ( what he says and how he says it) use quotations if necessary.
16. If you remember something important after you have completed your documentation, write
“ late entry” and make the note.
17. If information on a flow sheet does not pertain to your patient, write N/A for not applicable,
leaving it blank appears that it was not addressed or an oversight.

Nursebitz.com Alert: Make sure that each page has the patients name on it. Just last name is not acceptable, as it could become misplaced, and posted on the wrong chart of someone else with the same last name. These good rules of charting is a good start to successful documentation.

]]> http://nurseonline.org/dos-to-good-charting-in-patients-medical-record/feed/ 0 Duties of a Operating Room Nurse http://nurseonline.org/the-duties-of-a-operating-room-nurse/ http://nurseonline.org/the-duties-of-a-operating-room-nurse/#comments Sun, 20 Sep 2009 13:24:00 +0000 Site Admin http://nurseonline.org/the-duties-of-a-operating-room-nurse/ Pre-operatively
Preparation of patients for their procedure involves ensuring pre-medication is administered, the patient/guardian has given written consent, the required blood-tests have been done, identification labels and identification bracelets are correct, all allergies have been recorded in the patient’s notes and that the patient has been fasted appropriately.

Post-Operatively
Post-operatively the patient must be closely observed for signs of shock, arrest. The surgical nurse also ensures the wound created by the surgery is intact, and must be knowledgeable in wound care and the care of surgical drains. Surgical Nurses are responsible for the management of pain and post-operative nausea and vomiting, which are common post-operative side effects. The surgical nurse is also responsible for the discharge of the patient and giving the patient information on support systems and measures necessary to their recovery. ]]> http://nurseonline.org/the-duties-of-a-operating-room-nurse/feed/ 1 Nursing Interventions for Diarrhea http://nurseonline.org/nursing-interventions-for-diarrhea/ http://nurseonline.org/nursing-interventions-for-diarrhea/#comments Fri, 04 Sep 2009 14:34:00 +0000 Site Admin http://nurseonline.org/nursing-interventions-for-diarrhea/ Diarrhea is the condition of having frequent loose or liquid bowel movements. Acute diarrhea is a common cause of death in developing countries and the second most common cause of infant deaths worldwide. The loss of fluids through diarrhea can cause severe dehydration which is one cause of death in diarrhea sufferers. Along with water, sufferers also lose dangerous amounts of important salts, electrolytes, and other nutrient

Therapeutic Interventions

  1. Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management.
  2. Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient. Friction and running water effectively remove microorganisms from hands. Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or central line care). Use of disposable gloves does not reduce the need for hand washing.
  3. Limit visitors. This reduces the number of organisms in patient’s environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. The most common modes of transmission are by direct contact (touching) and by droplet (airborne).
  4. Encourage intake of protein- and calorie-rich foods. This maintains optimal nutritional status.
  5. Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated). Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract infection (UTI).
  6. Encourage coughing and deep breathing; consider use of incentive spirometer. These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia.
  7. Administer or teach use of antimicrobial (antibiotic) drugs as ordered. Antimicrobial drugs include antibacterial, antifungal, antiparasitic, and antiviral agents. All of these agents are either toxic to the pathogen or retard the pathogen’s growth. Ideally, the selection of the drug is based on cultures from the infected area; this is often impossible or impractical, and in these cases, empirical management usually is undertaken with a broad-spectrum drug.
  8. Place patient in protective isolation if patient is at very high risk. Protective isolation is established if white blood cell counts indicate neutropenia (<500>
  9. Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes.
  10. Teach patient or caregiver to wash hands often, especially after toileting, before meals, and before and after administering self-care. Patients and caregivers can spread infection from one part of the body to another, as well as pick up surface pathogens; hand washing reduces these risks.
  11. Teach patient the importance of avoiding contact with those who have infections or colds.
  12. Teach family members and caregivers about protecting susceptible patient from themselves and others with infections or colds.
  13. Teach patient, family, and caregivers the purpose and proper technique for maintaining isolation.
  14. Teach patient to take antibiotics as prescribed. Most antibiotics work best when a constant blood level is maintained; a constant blood level is maintained when medications are taken as prescribed. The absorption of some antibiotics is hindered by certain foods; patient should be instructed accordingly.
  15. Teach patient and caregiver the signs and symptoms of infection, and when to report these to the physician or nurse.
  16. Demonstrate and allow return demonstration of all high-risk procedures that patient or caregiver will do after discharge, such as dressing changes, peripheral or central IV site care, peritoneal dialysis, self-catheterization (may use clean technique). Bladder infection is more related to overdistended bladder resulting from infrequent catheterization than to use of clean versus sterile technique.
]]> http://nurseonline.org/nursing-interventions-for-diarrhea/feed/ 0 DOH Smoking Cessation Program http://nurseonline.org/doh-smoking-cessation-program/ http://nurseonline.org/doh-smoking-cessation-program/#comments Sat, 08 Aug 2009 03:41:00 +0000 Site Admin http://nurseonline.org/doh-smoking-cessation-program/ The tobacco plant, scientifically known as Nicotiana tabacum, is a plant grown for its leaves, which are smoked, chewed, or sniffed for a variety of effects. Tobacco is considered addicting because it contains the chemical nicotine. Sniffing and chewing tobacco originated in North America and Europe. It was Christopher Columbus who introduced tobacco into Europe. It then became very popular with the Portugese, Spanish, French, British, and Scandinavians.

Why is cigarette smoking dangerous?

In 1960’s, medical research on tobacco showed smoking to be strongly linked to heart and lung diseases. Smoking may be even more dangerous now than 30 years ago because the lower levels of tar and nicotine in cigarette brands make smokers inhale more deeply. In the US . . . .

* Only 42 of male lifelong smokers reach the age of 73 compared to 78% of non-smokers
* 25.7% of the adult population (47 million people) continue to smoke despite repeated warnings on the hazards of cigarette smoking. 28% of the male population and 23% of women smoke
* Despite the known dangers of smoking, television, radio, and print ads continue to promote a number of cigarette brands

What are the chemicals in tobacco smoke?

Tobacco contains nicotine, as well as tar. Both substances get deposited in the bronchi and the lungs. The other chemicals found in tobacco are:

1. Acetone
2. Ammonia
3. Carbon Monoxide
4. Carbon Dioxide
5. Hydrogen Cyanide
6. Methane
7. Benzopyrene

These chemicals are the major factors responsible for smoking related diseases like coronary heart disease, atherosclerosis, stroke, emphysema, acute bronchitis and cancers of the nose, pharynx, larynx (voice box), and lungs

What are the effects of nicotine on the body?

  • Nicotine gives the so-called “positive effects” which include
  • Enhancement of memory and alertness
  • Improvement of skills and work performance
  • Alteration of mood, reduced stress, improvement in “sociability” and even euphoria

However, these effects are fleeting and are far outweighted by negative effects. These include:

1. Shortness of breath
2. Chronic cough
3. Increased heart rate and blood pressure
4. “Ulcer-like” stomach pains (hunger pains), nausea and diarrhea
5. Reduction of fertility
6. Early onset of menopause in women
7. Tremors, especially in the inexperienced user
8. Sweating with the smell of nicotine

Others related to gastro-intestinal effects:

1. Appetite suppression specifically for simple carbohydrates (sweets)
2. Inability to taste food
3. Decreased efficiency of food digestion and metabolism

What is second-hand smoke?

Second-hand smoke is smoke exhaled by a smoker and inhaled by other people. Non-smokers who are exposed to second-hand smoke are more at risk because the particles in the exhaled smoke are smaller. They reach deeper into the lungs of the passive smokers.

The unfortunate non-smoker exposed regularly to second-hand smoke, is prone to specific health risks which include:

1. Increased risk of heart disease
2. Increased risk of lung cancer
3. Increase frequency of respiratory infections and asthmatic bronchitis in infants and children
4. Chronic irritation of the eyes, nose and throat especially among children

What are the long-term effects of cigarette smoking?

Long-term smoking can contribute significantly to the acceleration of the following health problems:

1. Nicotine addiction
2. Coronary artery disease – at least 20% of deaths are smoking-related
3. Heart disease – Smokers in their 30s and 40s have a heart attack rate that is five times
their non-smoking peers
4. Hardening of the arteries and complication of blocked arteries, hypertension, blood clots
5. Stroke – People who smoke a pack a day have almost two and a half times the risk of getting a stroke
6. Peptic ulcer disease
7. Lung diseases – chronic obstructive pulmonary diseases such as chronic bronchitis and
emphysema; smoking caused nearly 85,000 deaths in 1990 due to these diseases.
8. Cancers – oral, especially of the respiratory tract and the oral cavity, nose, pharynx, larynx,
lung, cervical, urinary bladder, kidney, and pancreas; smoking accounts for 85% of all lung
cancers
9. Disease of the oral cavity, e.g., irritation and infection of the gums and teeth
10. Delayed wound healing

Smoking can cause the following problems in women:

1. Reproductive disturbances (such as, infertility)
2. Problems during pregnancy include:
a. Fetal abnormalities and even death
b. Low-birth weight infants

Why is very hard to quit smoking?

Withdrawal is a difficult process. About 70% of smokers want to quit. In one study of women smokers who wanted to quit, 80% of them were unable to. This is because nicotine increases the activity of dopamine, a chemical in the brain that elicits pleasurable sensations. Even after years of non-smoking, about 20% of ex-smokers still have occasional cravings for cigarettes.

What are the signs and symptoms of nicotine withdrawal?

Withdrawal symptoms begin as soon as 4 hours after one decides to quit smoking or after the last cigarette, generally peak in intensity at three to five days, and disappear after two weeks. These symptoms start with headache, anxiety, irritability, tremors, poor concentration, and hunger pains. Other signs and symptoms include insomnia and depression, sweating, constipation and diarrhea.

What are the benefits of quitting smoking?

Chronologically, these are the benefits when one decides to quit smoking:

1. Within 20 minutes, the blood pressure and pulse rate drop to normal, the body temperature of the hands and feet returns to normal.

2. Within 8 hours, the carbon monoxide level in blood drops to normal and the oxygen level I blood increases to normal.

3. Within 24 hours, the risk of a sudden heart attack decreases.

4. Within 48 hours, the nerve endings begin to regenerate and a person’s ability to smell and taste begins to return to normal.

5. Within 2 weeks to 3 months, blood circulation improves and lung function increases up to 30%.

6. Within 1 to 9 months, overall energy increases, signs and symptoms of coughing, nasal congestion, fatigue, and shortness of breath are markedly reduced. Natural cleansing mechanisms of the respiratory tract returns to normal, so that the body is able to handle mucus, clean the respiratory tract, and prevent respiratory infections.

7. Within 1 year, risk of coronary heart disease is reduced by 50%.

8. Within 5 years, the risk of dying from lung cancer is reduced by 50%. The risk of cancer of the mouth is half that of a tobacco user.

9. Within 10 years, the risk of dying lung cancer, stroke and heart attack is the same as that of a non-smoker’s.

When is the best time to quit smoking?

The sooner a smoker quits smoking, the better. It is never too late to quit. No one is too old too quit. Because the first two weeks are critical success, smokers should seek all the help they can during this period.

Here is a tip to help smoker decide when to quit smoking:

A smoker should choose a particular date to quit when his level of stress is lowest.

Example: Women should not start during the premenstrual period when stress is high.

What are ways to quit smoking?

1. Scheduled reduction – the process of slowly reducing the number of cigarettes per day until one has stopped completely.
2. Nicotine Replacement Therapy (NRT) – a smoker who stops smoking is given small amounts of nicotine over a period of six weeks or more to reduce withdrawal signs. The nicotine is given either as chewing gum. patch, nasal spray or cigarette-like inhaler. Consult your physician about NRT.
3. Totally quitting smoking without any outside help.

What should smokers do while they are quitting?

1. Exercise. Take deep breaths, dance, run, wall jump up and down, stretch.
2. Drink plenty of water and eat fruits and vegetables. Take plenty of vitamins and minerals.
Carrots, apples, singkamas, chewing gum, and candies are good munching foods to replace
the feel of a cigarette in the mouth.
3. Take naps, warm baths or showers during intensive cravings to smoke.
4. Tell friends and family that you have stopped smoking. This will make you feel embarrassed
when they catch you smoking.
5. Change activities or habits that are associated with smoking. For instance, find other ways to
finish a meal without smoking. Go out for a walk, go to a place where smoking is prohibited,
doodle instead of smoking while talking on the phone.

Advice to smokers:

While is was once a fad to smoke, it has now become dangerous to health. Smoking is abnormal. It is very addicting and very hard to stop. Smoking not only affects other people who inhaled second-hand smoke. Smoking contributes significantly to diseases that shortens life and is leading cause of death like heart attack, stroke, respiratory diseases which make smokers “pulmonary cripples” as in asthma, emphysema, bronchitis, recurrent infections, and cancer.
(Department of Health Philippines) http://www.doh.gov.ph
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