To date, a number of charting formats have been used for documentation. These include block notes, with a single entry covering an entire shift (e.g., 7 to 3 p.m.); narrative
INCREASES
CHAPTER 3CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
Figure 3.3 Mind map for Mr. R.S.
ND: infective Self-Health Management - review disease process - BS monitoring - insulin administration - s/s hyper/hypoglycemia - dietary needs - foot care
Blood sugar 450 thirst/wt loss
ND: impaired peripheral Tissue Perfusion - feet when in chair
- increase fluids/l&O - safety precautions - foot inspection
pulses numbness & tingling
Pressure ulcer Perform
RS
RFS
Understand DM and treatment Self-admin
insulin
Maintain hydration
Understand relationship of DM to circulatory changes
ND: impaired Skin Integrity - wound care - dressing change - infection precautions - Dicloxacillin
Wound clean/pink
No drainage/
erythema ND: unstable Blood Glucose Level
- fingerstick 4X day - 2400 cal diet
3 meals/2 snacks - Humulin N - Glucophage/DiaBeta
FBS < 120 leads
to
due to
demonstrates
impairs healing
DM Type 2 complication
increases risk for
ND: acute Pain - foot cradle - Darvocet N
Pain free
Full wt.
bearing causes
timed notes (e.g., 8:30 a.m., ate 100% of breakfast); the problem-oriented medical record system (POMR) to record the subjective and objective data, analysis of the data, and the resulting plan (SOAP); and flow sheets with charting by exception, to name a few. The POMR can provide thorough documentation, but it was designed by physicians for episodic care and requires that the entries be tied to a prob- lem identified from a problem list.
A charting system format created by nurses for docu- mentation of frequent or repetitive care is Focus Charting
®. It was designed to encourage looking at the client from a positive rather than a negative (or problem-oriented) per- spective by using precise documentation to record the nurs- ing process. Recording of assessment, interventions, and evaluation information in data, action, and response (DAR) categories facilitates tracking and following what is happen- ing to the client at any given moment. Charting focuses on client and nursing concerns, with the focal point being client status and the associated nursing care. The focus is always stated in a way that reflects the client’s concerns or needs rather than a nursing task or medical diagnosis. Thus, the focus can be a client’s problems or concerns or nursing di- agnosis; signs and symptoms of potential importance, for in- stance, fever, dysrhythmia, and edema; a significant event or change in status; or a specific standard of care or hospital policy. An expansion of this format is DATRP: data, action, teaching, response, and plan.
A more recent way to evaluate and document the
client’s progress (response to care) is by using clinical
pathways. These pathways were originally developed as
tools for providing care in case management systems and
are now used in many settings. A clinical pathway is a
type of abbreviated plan of care that is event oriented
(task oriented) and provides outcome-based guidelines for
goal achievement within a designated length of stay. The
pathway incorporates agency and professional standards
of care and may be interdisciplinary, depending on the
care setting. As a rule, however, the standardized clinical
pathways address a specific diagnosis, condition, or pro-
cedure, such as myocardial infarction, total hip replace-
ment, or chemotherapy, and do not provide for inclusion
of secondary diagnoses or complications, such as an asth-
matic client in alcohol withdrawal. In short, if the client
does not achieve the daily outcomes or goals of care, the
variance is identified and a separate plan of care must be
developed to meet the client’s individual needs. There-
fore, although clinical pathways are becoming more com-
mon in the clinical setting, they have limited value (in
place of more individualized plans of care) as learning
tools for students who are working to practice the nursing
process, critical thinking, and a holistic approach to meet-
ing client needs. A sample clinical pathway (Fig. 3.5) re-
flects Mr. R.S.’s primary diagnostic problem: nonhealing
wound, diabetic.
FINISHED YES NO
NO
YES YES
NO Does R.S. display signs of
wound healing (e.g., lesion has decreased in width and/or depth; lesion has decreased drainage; wound edges are clean/pink)?
Reassess using initial assessment factors.
Is diagnonsis validated?
Record new assessment data. Record REVISED.
Enter new diagnosis, objectives, target date, and orders. Delete unvalidated diagnosis.
Record data, e.g., lesion has increased in depth to 4 mm and in width to 3 cm.
Drainage increased from approximately the size of a dime to a 50-cent piece on dressing. Record CONTINUE and change target date. Alter nursing orders as necessary.
Start new evaluation process.
Did evaluation show a new problem had arisen?
Record data, e.g., lesion has decreased in depth to 2 mm, and in width to 2 cm.
Has no drainage. Record RESOLVED (may wish to use CONTINUE until lesion has completely healed).
Figure 3.4 Outcome-based evaluation of the client’s response to therapy. (Adapted from Newfield, SA, et al: Cox’s Clinical Applications of Nursing Diagnosis, ed 5. FA Davis, Philadelphia, 2007.)
CHAPTER 3CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE
CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathway Should Be Documented in Progress Notes
ND and Categories of Care Adm Day 1 6/28 7pmDay 2 6/29Day 3 6/30Discharge 7/1 impaired Skin/ Tissue Integrity Referrals Diagnostic studies Additional assessments Medications Client education Additional nursing actionsActions/Goals: Wound culture/sensitivity Gram’s stain Random blood glucose Fingerstick BG hs VS qid I&O/level of hydration qd Character of wound tid Level of knowledge and prior- ities of learning needs Observe for signs of antibiotic hypersensitivity reaction Antibiotic: Dicloxacillin 500 mg PO q6h Antidiabetic:Humulin R insulin 10 units SC on adm Provide: Understanding Your Diabetes Up ad lib NS soaks/dressing change tid Actions/Goals: Verbalize under- standing of condition Display blood glu- cose WNL (ongoing) Dietician & determine need for: Home care Physical therapy Visiting nurse CBC, electrolytes Glycosylated Hb, Serum lipid profile Fingerstick BG qid/call>250 Chest x-ray (if indicated) ECG (if indicated) Anticipated discharge needs Antibiotic: same Antidiabetic: Humulin N insulin 10 U SC q AM DiaBeta 10 mg PO bid Glucophage 500 mg PO daily Film Living with Diabetes Demonstrate and practice tasks: 1. Fingerstick BG 2. Insulin administration 3. Wound care 4. Routine foot care
→ → Actions/Goals: Be free of signs of dehydration Wound free of purulent drainage Verbalize understanding of treat- ment needs Perform self-care tasks No. 1 and 3 correctly Explain reasons for actions → →VS each shift
→ → Antibiotic: same Antidiabetic: same Group sessions: Diabetic management → →
Actions/Goals: Wound edges show signs of healing process Perform self-care task No. 2 correctly Explain reason for actions Plan in place to meet discharge needs Fingerstick BG bid if stable → →D/C → Antibiotic: same Antidiabetic: same Practice self-care task No. 2: insulin administration Review discharge instructions → →
→ → → →
CP: Non-healing Lesion—Diabetic. ELOS: 3 Days—Variations from Designated Pathwa y Should Be Documented in Progress Notes
(Continued) acute Pain Additional assessments Medications Allergies: -0- Client education Additional nursing actions Actions/Goals State pain relieved or minimized with 1 hr of anal- gesic administra- tion (ongoing) Verbalize under- standing of when to report pain and rating scale used Verbalize under- standing of self- care measures No. 1 and 2 Explain reason for actions Characteristics of pain Level of participation activities Individual analgesic needs Analgesic:Darvocet-N 100 mg PO q4h PRN Orient to unit/room Guidelines for self-report of pain and rating scale 0–10 Safety/comfort measures: 1 elevation of feet 2 proper footwear Bed cradle as indicated Actions/Goals Verbalize under- standing of self- care test No. 3 Explain reason for actions→ → → Analgesic:same Safety/comfort measures: 3 prevention of injury Actions/Goals Able to participate in usual level: ambulate full weight bearing
→ → → Analgesic:same Actions/Goals State pain-free/ controlled with medication Verbalize under- standing of correct medica- tion use
→ → → Analgesic:same Review discharge medication instructions: dosage, route, frequency, side effects
ND and Categories of Care Adm Day 1 6/28 7pmDay 2 6/29Day 3 6/30Discharge 7/1 Figure 3.5 Sample Clinical Pathway.
CHAPTER 3CRITICAL THINKING: ADAPTATION OF THEORY TO PRACTICE