6-1 Chapter 6 Nurse Note Documentation Level 2 © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill

6-2 Chapter 6 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)

I&O (Intake and Output) Intake – All fluids Oral Parenteral, including blood products and meds Output – All fluids Urine Emesis Drainage tubes