Nursing Doc Unud

8/10/2019 Nursing Doc Unud

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NURSINGDOCUMENTATION

Siluh Nyoman Alit Nuryani, BoN, MN


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OVERVIEW

Overview of Nursing Documentation

Vocabulary related

Useful ConversationGrammar Preference

Learning Task


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WHYNURSINGDOCUMENTATION

IMPORTANT..

Record keeping is an integral part of nursing and

midwifery practice. It is a tool of professional

practice and one that should help the careprocess. It is not separate from this process

and it is not an optional extra to be fitted in if

circumstances allow.

(Nursing & Midwifery Council April 2002)


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THEEXPECTATIONOFAREGISTERED

NURSEINTHEFUTURE

The quality of your record keeping is a

reflection of the standard of your professional

practice.

Good record keeping is a mark of a skilled and

safe practitioner

Promote patient safety


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WHOREADNURSINGNOTES?

Nurses

Doctors

Medical and Nursing students Dieticians

Physiotherapists

Other healthcare co-workers

AFFECTING EVERYBODY IN A TEAM!!!!


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NURSING DOCUMENTATION

PROMOTES

High standards of clinical care

Continuity of care

Better communication & dissemination ofinformation between members of the MDT

An accurate account of treatment, care planning anddelivery of care

The ability to detect problems at an early stage

That you have taken all reasonable steps to care forthe patient and any action or omission on your part

have not compromised their safety

A record of arrangements you have made for thecontinuing care for the patient

NMC 2002


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LEGALISSUES

Nursing records can be used in the

court

To review patient complaint

To review unexpected death

To review for visum et repertum


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STANDARDNURSINGDOCUMENTATION

Factual, consistent and accurate

Written as soon as possible after an event hasoccurred, providing current information on thecare & condition of the patient

Written clearly in such a manner that the textcan not be erased

Written so that any alterations or additions aredated, timed and signed in such a way that theoriginal entry can still be clearly read


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NURSINGDOCUMENTATIONSTANDARD

F.A.C.T.U.A.L

F = Focused on patient

A = AccurateC = Complete

T = Timely

U = Understandable

A = Always Objective

L = Legible

(ANMC 2008)


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NURSINGPROCESS

Refer to a rationale

steps in a

systematic

approach to a

problem solvingassessment,

Diagnosis,

Planning,

Intervention,

and evaluation)


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NURSINGPROCESS

Assessment consists of :

Assessing Nursing/Illness History : Patients

identity, chief compliant, HPI(history prsent illness),

PNH (past Nursing History), Family history)

Obs, VS and general apppearance

Physical Examination

Result of Diagnostic test (urine, blood, X ray etc)

Al l of the above shou ld be com pleted on

adm ission and reviewed on transfer.


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THEFIVEATTRIBUTESOFSYMPTOMS

P (Provokes) : including environmental factors

personal activities, emotional reactions, etc)

Q (quality ) : what is it like? R (region) : Where is it? Does it radiate

S (severity ) : How bad is it?

T ( Time ) : When did it start, how long did it last,

how often did it come?


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NURSINGDIAGNOSIS

P = Problemsof human responses (biopsycho-

socio-spiritual)

E = Etiology( Pathophysiology, situation,medication, maturation)

S = Signs and symptoms (result of interview,

observation, physical examination, and diagnostic

test


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INTERVENTION: PLANNINGAND

IMPLEMENTATION

Principles of planning should be SMART(Specific,

Measurable, Achievable, Reasonable, and time )

The client record contains daily documentation ofnursing activities

The plan of care is implemented

Competently

Caringly Creatively


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PLANNING

Nursing diagnosis Goal Objective Nursing Orders

Altered nutrition: less

than body

requirements related

to excessive vomiting

Symptoms are

vomiting three times,

.

Within 48-72 hours:

Eating portion =

until 1 portion each

meal

Body weight

increased - kg

Albumin normal

Monitor intake and

output daily

Provide good oral

care

Create comfort

environment

Verbalize importantadequate nutrition

(high calories and

protein)

Maintain present

weight


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IMPLEMENTATION

Problem Implementation Evaluation

Altered Nutrition : less

than body

requirements

Creating comfortable

environment

Demonstrate to keep

oral hygiene

Teaching importance

nutrition for healthy

Increasing her

appetite with askfavourite food

Increasing her

appetite

Eating portion each

meals, drink milk 200cc twice a day

Albumin : 2.7

Anemis sign -


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EVALUATION

SOAP

Altered nutrition: less than body requirements

related to nutrition intake

S= she said that she loss her appetite O= weight : 22.5 kg, portion of eating

A = problem solved but still can happen again since

patient has severe infection

P= Teach patients family to support by providingfavorites meals


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USEFULCONVERSATION

How was your sleep last night?

Do you still feel painful on your surgery site?

Is there any pain in any part of your body?

How intense is the pain on scale of 0 to 10 (with 10being the worst possible pain?)

Can you move your finger?

Do you still have nausea and vomiting

Do you feel pressure on your cast? How was your urine output?

How was you bowel habits?


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VOCABULARYRELATED

Antibiotic

Antifungal

Antivirus

AntidiuretikAntidepressant

Antipyretic

Cough medicine

Chemotherapy

Radiotherapy

Hypoglicemia,

Hyperglicemia

Diet

Appetite

Dysphagia

Rash Dryness

Constipation

Diarrhoea

Incontinence

Sleep/rest pattern

insomnia


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VOCABULARYRELATED

Nutrition pattern

Mental status

Conscious/unconsciou

sness Consent form

Discharge planning

Falls risk assessment

Refusal of treatment Past medical history

Medication

Alert

Joundice

Dyspnea

Constipation Cyanosis

Anorexia

Inflamation

Respiration

edema


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CONT.

Infection

Nosocomial infection

Virus

Viral infection Contaminated food or drink

Feces/urine

Fever

Diarrhea

HIV/AIDS

TB/tuberculosis


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CONT.

Injury

Sprain

Dislocation

Fracture Rupture

Swelling

Pain

Cast

Capilary refill


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GRAMMARFOCUS: PREFERENCE

Kelebihsukaan thd suatu benda/kegiatan

S + Like + Noun/Gerund + Better Than +

Noun/gerundExample

Mr John like walking better than swimming

S + Prefer +Noun/Gerund + to + Noun/GerundExample

Peter prefer eating porridge to eating steam rice


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CONT.

S + prefer + to Infinitive + rather than +

infinitive/gerund/noun

Example

Christy prefer to go to Australia rather than toEngland

S + would prefer + to infinitive + (rather) than +

infinitive/gerund/nounExample

Lina would prefer to meet orthopedics rather than

meeting general surgeon


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CONT.

S + would rather + infinitive + than +

infinitive/gerund/noun

Example :

Tony would rather take oral medications thaninjection


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CONT.

Implied causative

S + Prefer + Someone (subject)+ to Infinitive

ExampleDoctor prefer this patient to take oral medication

S + would rather + someone + To infinitive + verb

Example

I would rather this patient to go to operating

theatre immediately


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CONT.

Comparison of Equality

As + Adjective + as

Example :

Please take a deep breath as deep as you can!

Squeeze my hands as strong as you can


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CASESTUDY

A 45 year old male, complaining severe cough, and

difficult to breath for 3 months. He had been taken

medicine from drug store but he hasnt recovery

from his illness. He works as driver and live in poor

family. His father had Tuberculosis , no allergies tomedicine. Thoraks : TB

Please fill out assessment form and make nursing

care plans and evaluation using SOAP based uponthis case

Nursing Doc Unud

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