DOCUMENTATION: written, legal record of in solving the problem

all pertinent interactions with the client of the patient)

General rule: what is not written in the c. Entry in the forms-

documentation is not done chronological (timing is
important)
Parts of documentation: i. Old files are always
attached to the back
1. Registration sheet: data
demographics d. Progress notes- written in
2. Health assessment: physical narrative form
assessment i. Description of the
3. Daily checklist- summary of what status of the problem,
you are doing to your patient nursing interventions,
4. Nurse’s progress notes: nurses have patient responses
to write what they did to the patient, and needed revisions
the interventions. Nurses must do to plan of care
this before they go home
5. Vital signs sheet: checked every 4 2. Problem-oriented records:
hours designed like a nursing process
6. I & O sheet: input and output of the a. organized around a patient’s
patient problem rather than around
7. Health teachings: if the patient is for sources of information
discharge, discharge medications, b. the entire healthcare team
follow-ups works together in identifying
8. Medical administration record: a master list of patient
medications problems and contributes in
9. Laboratory results: CT scan reports, collaborating to the plan of
imaging results care
10. Doctor’s order c. progress notes clearly focus
on patient problems
Types of documentation d. In POR, miscommunication
problems are lesser
1. Traditional
a. Used in the Philippines up Comparison of Nursing process and POR
until now 1. Assessment- data- base
b. Each healthcare group keeps 2. Nursing diagnosis- problem list
its data on its own separate 3. planning - initial plan of care
forms 4. Implementation- Progress notes:
i. Nurses, physicians, SOAPIE: subjective, objective,
laboratory, x-ray analysis, planning, intervention and
personnel (works on evaluation
their part contributing 5. Evaluation- discharge summary
Purpose of patient records - Avoid words such as good, average,
normal, or sufficient
1. Communication - Avoid generalizations
2. Care planning - Note problems as they occur in an
a. When a patient is admitted, orderly, sequential manner, record the
nurses check the patient and nursing intervention and the patient’s
then they will have a plan for response; update problems or delete as
one week appropriate
3. Quality review - Document all medical visits and
a. Complains of the patient can consultations
also be recorded - Document in a legally and prudent
4. Research manner
5. Health care analysis - Document the nursing response to
a. This can be checked through questionable medical orders or treatment
patient’s record
6. Education 2. TIMING
a. Student nurses are allowed - Indicate each entry, the date and
to check a patient's record both the time the entry was written and the
but not allowed to take time of pertinent observations and
pictures of it. It is for interventions
education. - Document nursing interventions as
7. Legal documentation closely as possible to the time of their
- What is documented can be execution
used in the court - Never leave the unit for a break
8. Reimbursement when caring for a seriously ill patient until all
- Insurance companies are significant data are recorded
allowed to check patient’s - Never document interventions
record before carrying them out
9. Historical Documentation
- Famous patient’s records can 3. FORMAT
be included in historical - Chart on the proper form as
documentation designated by agency policy
- Print or write legibly in dark ink to
ensure permanence
GUIDELINES FOR EFFECTIVE - Use correct grammar and spelling
DOCUMENTATION: - Use standard terminology. Only
commonly accepted terms, abbreviations
1. CONTENT and symbols
- Nursing medical knowledge - Date and time each entry
- Enter information in a complete, - Chart nursing interventions
accurate, relevant and factual manner chronologically on consecutive lines; never
- Record patient findings rather than skip lines and draw a single line through
your own interpretation of findings blank spaces
4. ACCOUNTABILITY
- Sign your initial, last name, and title
to each entry
- Do not sign notes describing
interventions NOT performed by you that
you have no way of verifying
- Do not use dittos, erasures or
correcting fluids. A single line should be
drawn through an incorrect entry and word
“ERROR” should be printed above or
bedside the entry, sign the entry and rewrite
the new ones identify each page of the
record with the patient’s name and
identification number
- Recognize that the patient record is
permanent. Follow agency policy pertaining
to the color of ink and the type of pen or ink
to be used

5. CONFIDENTIALITY
- Patients have moral and legal rights
to expect that the information contained in
their patient health record will be kept
- Most agencies allow students to
access the patient records for educational
reasons
- Keep in strict confidence all the
information they learn by reading patient
records.
- Actual patient names and other
identities should not be used in written or
oral student reports
ABBREVIATIONS, ACRONYMS AND FHS, FHR: Fetal Heart Sound, Fetal Heart
SYMBOLS USED BY HEALTH Rate
PRACTITIONERS Fx: Fracture
GIT: Gastrointestinal Tract
ABG: Arterial Blood Gas G1: Pregnant ( Gravida 1)
ADL: Activities of daily living Gtt: Drop
- Everyday routines GUT: Genitourinary Tract
ABO: Main Blood Group ICU: Intensive Care Unit
ANST- after negative skin test I&D: Incision and Drainage
AP: apical pulse Ig: Immunoglobulin
A-P: anterior- posterior view, combined with IM: Intramuscular
CXR (Chest X-Ray) IV, IVP: Intravenous, Intravenous Push
B & B: bowel and bladder IVPB: Intravenous Piggyback
BE/Bae: Barium Enema IVP: Intravenous Pyelogram
BCG: Bacille Calmette- Guerin KUB: kidney, ureter, bladder
- Protects us from TB 50% KVO: Keep vein open
BP: Blood Pressure LLQ, LUQ: Lower Left Quadrant, Left upper
BRP: Bathroom Privileges quadrant
BS: bowel sounds NG: Nasogastric
BR: bed rest NGT: Nasogastric Tube
BSC: bedside commode NS, N/S: Normal Saline
BSD: Bedside drainage Oint: Ointment
Bx: Biopsy OPD: Out-Patient Department
C: Celsius OR: Operating Room
C1, C2: Cervical spine OT: Occupational Therapy
CA: Cancer PE/PX: Physical Examination
Cap: Capsule Postop, preop: Postoperative, preoperative
Cath: Catheter RBC: Red blood cell
CBC: Complete Blood count ROM: range of motion
CCU: Coronary Care Unit (patients with a AROM: Active Range of Motion
cardiac problem) PROM: Passive Range of Motion
Cl liq: Clear Liquid RLQ: Right lower quadrant
CNS: Central Nervous System RUQ: Right Upper Quadrant
CPR: Cardiopulmonary resuscitation SOB: Shortness of breath
(usually happens in code blue) WBC: White Blood Cells
CS: Cesarean Section
CSF: Cerebrospinal Fluid
CVA: CerebroVascular Accident
CVD: CerebroVascular Disease
CXR: Chest X-Ray
DR: Delivery Room
Drsg: Dressing
ECG/EKG: Electrocardiogram
EEG: electroencephalogram
ABBREVIATIONS/ACRONYMS USED IN
DIFFERENT AFFILIATION
INSTITUTIONS/AGENCIES

AB: abdominal binder

ADCF: Avoid dark colored foods
AUB: abnormal uterine bleeding
BTL: Bilateral tubal ligation
CBG: capillary blood glucose
HGT: hemogluco test
CIL: cephalic in labor
CTT connected to BSD: Chest Tube
Thoracostomy
HD: hemodialysis
IFC: indwelling foley catheter
IPTL: In Preterm Labor
KMC: Kangaroo Mother Care
KFC: Kangaroo Father Care
LTCS: Low Transverse Cesarean Section
NSD: Normal Spontaneous Delivery
NTG Patch: Nitroglycerin Patch
OF: osteorized feeding
RMLE: Right-MedioLateral Episiotomy
UTZ, UTS: Ultrasound
VBAC: Vaginal Birth after Cesarean Section
IV THERAPY OVERVIEW
- Treatment that infuses fluids, electrolytes, medications, nutrients, blood or blood products into a vein
- Used to administer fluids, drugs, and nutrients when a patient cannot take them orally (for patient who has
acute gastroenteritis)
- Iv fluid- iv line- cannula

OBJECTIVES OF IV THERAPY:
• To restore and maintain fluid and electrolyte balance
• To administer medications, including chemotherapeutic agents, intravenous anesthetics, and diagnostic
reagents
• To transfuse blood and blood products
• To deliver nutrients and nutritional supplements

USES OF IV SOLUTIONS
- Know their classifications
- Know what are their uses
- Maintain or restore fluid balance when oral replacement is inadequate or impossible
- Maintain or replace electrolytes
- Administer water-soluble vitamins (for alcoholic patient)
- Provide a source of calories (D5)
- Administer drugs
- Replace blood and blood products
Note: IV fluids are considered as drugs

CLASSIFICATIONS OF FLUID REPLACEMENT

CLASS EXAMPLES USES

Crystalloids • Dextrose replacement and maintenance of
• Saline fluid levels
• Lactated Ringer’s
Colloids • Dextran volume expansion or plasma
• Amino Acids expander
• Hetastarch
• Plasmanate
Blood products • Whole blood Replacement of blood
• Packed RBC components
• Plasma
• Albumin
• Platelets
Lipids • Fat emulsions Supplementation of nutrients/
needs

TYPES OF IV SOLUTIONS:

TYPE EXAMPLES INDICATIONS CONTRAINDICATIONS

Isotonic • 0.9% NaCl (NS is • DHN • 0.9 NaCl – CHF,
no change the safest IV fluid • Blood loss fluid overload
range: 260-310 and can be used • hypernatremia • D5W- increased ICP
w/o doctor’s • D5LR- liver disease
order)
• Note: the only
solution that can
 be partnered to
blood transfusion
is NS
• Lactated Ringer’s-
common for OB
patients)
• 5% Dextrose in
water (D5W)
Hypotonic • 0.45% NaCl • DHN cerebral edema, increased
swell • 0.33% NaCl • Hyperglycemia ICP, hypotension,
range: lower • 0.25% NaCl neurosurgery, burns,
than 260 note: anything that is less trauma, malnutrition, liver
than 0.9% is considered disease
as hypotonic
Hypertonic • D5% in 0.45 • Post operation • Kidney disease
shrinkage Saline • Cerebral edema • Heart disease
range: higher • D5NS • DHN
than 310 • D5LR
• Dextrose 10% in
water
• Dextrose 20%
• Dextrose 50%
• D5IMB
• D5.3 NaCl
• D5NM

Note: anything higher

than 0.9% is hypertonic

IV FLUID COMPUTATION:

2 types of infusion sets:

1. Macrodrip Set
o for adult patients
o delivers 10, 15, 20 gtt/ml
o used for rapid or routine fluid delivery or KVO
o Abbott – 15
o McGraw- 15
o Cutter – 20
o Travenol- 10

2. Microdrip Set
o with needle
o pediatric fluid delivery
o 60 gtt = 1 ml
Planning/ Selecting Nursing - Actions that the nurse carries
Interventions but in collaboration with other
health team members
Nursing Interventions
- Activities the nurse plans and COMPONENTS OF NURSING
implements to help a patient achieve INTERVENTION
identified goal
- Any treatment based on clinical 1. PDx (Diagnostics) - monitoring
judgment and knowledge that the - Weighing, vital signs, Hgt
nurse performs to enhance patient monitoring
outcomes 2. PTx (Therapeutic) - skills
- Administering of Paracetamol
When Planning nursing interventions 500mg, 1 tab. Q4h as
ordered by the physician
The nurse should identify: 3. PEd (Education or Health
- What is to be done Teaching)- educating
- When (time and date) - Instruct the patient on wound
- Duration for each intervention dressing
- Any follow-up activity
- Date interventions were selected CRITERIA FOR SELECTING NURSING
- Sequence in which nursing activities INTERVENTIONS
are to be performed
- Signature of the nurse writing the 1. Safe and appropriate for the patient
plan of care 2. Congruent with other therapies
3. Develop the behavior described in
Types of nursing interventions the goal statement
4. Realistic
1. Independent/ nurse-initiated 5. Necessary to assess and monitor
interventions effect of medical treatment
- Actions that can nurses
perform without doctor’s WRITING INDIVIDUALIZED NURSING
order INTERVENTIONS ON CARE PLAN
- Involve carrying out nurse
prescribed-interventions Nursing interventions on the care plan
- Ex: bedmaking, TSB, vital should be:
signs, assessment
2. Dependent/physician-initiated - Dated when they are written
interventions - Reviewed regularly at intervals
- Involve carrying out
physician- prescribed orders EXAMPLES:
- Ex: ordering a drug
3. Interdependent/collaborative Nursing diagnosis: Impaired urinary
interventions elimination due to insufficient sphincter
control related to previous indwelling - promotive, preventive, curative,
catheterization rehabilitative

Goal: will void @ least once 6 hrs. After the Involves:

removal of catheter - Giving nursing care/carrying out the
planned nursing activities
Nursing Interventions - Delegating the care to another
health care team member
- Documentaing and validating care
- Continuing data collection

Aspects of the Nurse’s Role

1. Care aspects
2. Curative
3. Protective
4. Teaching
IMPLEMENTATION 5. Patient advocate
- Doing
- Delegating Principles on Implementation of Nursing
- Documenting Care
1. Maintaining the individuality of man
2. Consideration for the patient’s
IMPLEMENTATION safety, comfort and privacy
- Putting the nursing care plan into 3. Considering economy of ime, effort
action to achieve the expected and materials
outcome 4. neatness of the finished product
- Done to resolve/reduce identified
nursing problem on the patient, EVALUATION
with the patient, and for the - Determining the client’s response to
patient nursing interventions using the goals
- Nursing process is patient-centered of care as criteria whether they
were:
Purposes: - Met
- Promote health - Partially met
- Prevent illness - Not met
- Restore health
- Assist patient in achieving desired
health goals
- Facilitate coping with altered health
function
WHO, HOW, AND WHEN OF
EVALUATION
1. Recipient of care and care giver
2. Terminal behavior demonstrated by
the patient
3. Conditions under which the behavior
is expected to occur
4. Criterion for determining acceptable
performance

EVALUATION STATEMENT =
CONCLUSION + SUPPORTING DATA

Conclusion: met, partially met, not met

GOAL STATEMENT:
1. Will ambulate half the length of
hallway with assistance 3x a daily
EVALUATIVE STATEMENT
1. Goal partially met. Patient refused to
ambulate in the morning but walked
to the bathroom once in the
afternoon with the assistance of one
nurse.

GOAL STATEMENT:
1. Body temperature will decrease from
38.5 degrees celsius to 37.5
degrees celsius within 2hrs
administering TSB.
EVALUATIVE STATEMENT
1. Goal met. Body temperature went
down to 37.2 degrees celsius within
2 hours after TSB administration.

GOAL STATEMENT
1. Verbalization of decreased pain from
a scale of 2 to 1 (where 3= severe,
2= moderate, 1= mild, 0= no pain)
within the shift
EVALUATIVE STATEMENT
1. Goal not met. Patient verbalized that
the pain intensity remained the
same.