Nursing and Tepid Sponge Bath
DEFINITIONS:
Focus Charting - is a method for organizing health information in the individual 's record. It is a systematic approach to documentation, using nursing terminology to describe individual 's health status and nursing action.
Focus
• a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit • a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission • a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy • an acute change in an individual 's condition, i.e. respiratory distress, seizure, fever, discomfort • a significant event in an individual 's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization • a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition
COMPONENTS OF A FOCUS NOTE:
Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated.
Response: Description of individual 's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment.
Example:
Need: Comfort (or, Relief of pain)
D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10.
A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound.
R - Patient stated pain was "much better" 30 minutes later and
Focus Charting - is a method for organizing health information in the individual 's record. It is a systematic approach to documentation, using nursing terminology to describe individual 's health status and nursing action.
Focus
• a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit • a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission • a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy • an acute change in an individual 's condition, i.e. respiratory distress, seizure, fever, discomfort • a significant event in an individual 's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization • a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition
COMPONENTS OF A FOCUS NOTE:
Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events.
Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated.
Response: Description of individual 's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment.
Example:
Need: Comfort (or, Relief of pain)
D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. "I need something for pain now!" States pain is 9 on a scale of 10.
A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound.
R - Patient stated pain was "much better" 30 minutes later and