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

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Chapter 6

Nurse Note DocumentationLevel 2

© 2012 The McGraw-Hill Companies, Inc. All rights reserved.McGraw-Hill

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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)

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LO 6.1 DX (NURSING DIAGNOSIS)

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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

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• NANDA-I nursing dx, NOC, NIC– Widely recognized– Research based– Comprehensive

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• Nursing process– Assessment/diagnosis– Planning– Intervention– Evaluation

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• Assessment– First step in nursing process– Subjective data• Report of patient and/or family

– Objective data• Observations of nurse

– Observation– Auscultation– Palpation– Smell

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• 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

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• 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

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• 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

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• 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.

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LO 6.2 NOC (NURSING OUTCOMES)

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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

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LO 6.3 NIC (NURSING INTERVENTIONS)

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LO 6.3 NIC (Nursing Interventions)

• Nursing interventions– Nursing actions to help patient achieve goals• Facilitate wellness• Facilitate movement toward wellness

– Individualized for patient

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LO 6.4 MAR (MEDICATION ADMINISTRATION RECORD)

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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

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• 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

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• Elements included in MAR– Drug name– Drug dosage– Drug route– Frequency of administration– Administration times

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• Holding medications– Document reason medication not given per facility

policy– Notify licensed practitioner who ordered the

medication

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LO 6.5 I&O (INTAKE AND OUTPUT)

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6.5 I&O (Intake and Output)

• Intake– All fluids• Oral• Parenteral, including blood products and meds

• Output– All fluids• Urine• Emesis• Drainage tubes

Documents

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