DOCUMENTATION DRILLS FOR MENTAL HEALTH NURSING 1 By Donna Hess RN MS GOALS OF NURSING DOCUMENTATION Nursing Notes should be able to stand alone to describe the problem intervention and c by lq5646

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    By: Donna Hess RN, MS
 Nursing Notes should be able to stand alone to
  describe the problem, intervention, and client
 Nursing Notes should have related data
  organized to flow naturally.
 Nursing Notes should be readable for any
  healthcare professional to understand.
 Nursing Notes should be a snapshot of your care.

 Nursing Notes should clarify what care you have
 This technique of documentation is systematic
  and limits data to only pertinent (related)
  information based on the identified client
 P=Problem

 I=Intervention

 E=Evaluation

 P: Problems need to documented clearly,
  objectively, and honestly.
 I: Interventions need to be client focused, timely,
  and safe.
 E: Evaluations need to be ongoing and revised
  based on clients outcome goals.

 Allow  you to practice writing a nursing
  note clearly, objectively and honestly.
 Allow your nursing instructor the ability
  to evaluate your ability to transfer into
  writing the care you have performed.
 Allow your nursing instructor the ability
  to evaluate your ability to write clearly,
  objectively, and honestly.

   Read the scenario and create a nursing note.
   Nursing note must meet the following requirements:
    1. P-I-E Format
    2. Include only information related to the clients
         problem, intervention, and evaluation.
    3. Information must be organized and flow in a logical
    4. Information must be accurate and timely.
    5. Spelling and grammar must be appropriate to the
         content of the note.
    ***Remember the nursing note is a legal document.

                                                             Nursing Note:
   Ms. Jones is a 38 year old inpatient on the
    psychiatric unit. She was admitted (2) days ago          1200 Ms. Jones refused to eat and when
    with a diagnosis of bipolar disorder and a history        encouraged to eat she throw her fork at me
    of suicide. You, the nurse, have tried to involve         (Sally Lee RN). Ms. Jones has a new onset of
                                                              pacing the unit this AM and is restless. Ms.
    Ms. Jones in a variety of unit activities but she
                                                              Jones stated that when she gets out of this
    continues to be withdrawn. During your
                                                              facility she plans to kill herself. Mr. Lee a MH
    discussion session she continues to state that            Technician stated that he heard her talking to
    when she gets out of the facility she plans to kill       herself this AM but could not understand what
    herself.                                                  she was saying. Ms. Jones vital signs are:
    -1200 refused to eat and today when she was               P=58 (regular), RR=20, T=98.6, BP=110/70
                                                              and her baseline BP=148/76. Dr. Vot was
    encouraged to eat she displayed aggressive
                                                              notified concerning changes in Ms. Jones
    behaviors by throwing a fork at you, the nurse;
                                                              behaviors and vital signs. Dr. Vot phone
    she has been pacing the unit, appears restless,           orders taken and restated for clarification.
    and was heard talking to herself; vital signs:
    P=58 (regular), RR=20, T=98.6, BP=110/70                 1210 Ms. Jones room searched for medication
                                                              and found (2) untaken Lithium tablets under
    (baseline BP=148/76); notified physician (Dr.
                                                              her bed mattress. Ms Jones placed on suicide
    Vot) following orders obtained: evaluate room for
                                                              and elopement precautions per physicians
    untaken medications, lab for stat Lithium level,          order. Administered Thorazine 25 mg IM in
    administer Thorazine 25 mg IM Q2H for                     left deltoid per physician order with
    aggressive behavior times 4 doses; suicide &              aggressive behavior, throwing chair in hall.
    elopement procedure immediately                           Lab staff drew stat Lithium level per
                                                              physicians order.
    -1210 room evaluated for untaken medication &
    (2) Lithium tablets found under her mattress;                                                                7
    lab drew stat Lithium level; Thorazine 25 mg IM
    administer for throwing chair in hall;
   Betty Jones is a 17 year old girl who has been           Nursing Note:
    admitted to the hospital for anorexia. Betty tells
    the nurse she has trouble sleeping, has refused
    to eat at home and works out in the gym from 5-
    9pm every evening (7 days a week). Betty has
    lost 20 pounds in a month.
   The following occurs:
    -1000 admission assessment findings: Betty
    states she if fatigued and SOB with activity; vital
    signs: P=120 (irregular), RR=28, PO=94%,
    T=100, BP=100/60 (baseline from previous
    admission 128/78); admission weight 90 pounds
    & height 5’6”;complaints of being dizzy & has
    unsteady gait; right hand has burn scars on the
    fingers and back of hand; physician (Dr. Tram)
    orders: IV started with LR at 150 ml per hour for
    8 hours; monitor vital signs Q1H, bedrest with
    high risk for falls, Prozac 40 mg orally QD; send
    stat Electrolyte 7 & CBC with Differential
    -1010 IV started #24 gauge jelco in left forearm
    patient & inplace-infusing LR at 150 ml per hour
    ; Prozac 40 mg PO given; oriented to unit “high
    risk for falls” protocol; labs sent
    -1020 vital signs: P=100 (irregular), RR=26,
    T=100, PO=95%, BP=105//60; compliant with
    bedrest order; voided 75 ml of dark amber urine
   Jack Hawks is a 56 year old admitted to the          Nursing Note:
    hospital (4) times this year for threatening
    suicide and has been found to have burned
    himself with cigarettes. He has been on the
    inpatient psychiatric unit for 17 days and
    has been compliant with medication orders.
   The following occurs:
    -1000 Jack is happy and discusses with the
    nurse how well he is doing and hopes he will
    be discharged to home this week; vital signs:
    P=65 (regular), RR=20, T=98, PO=98%,
    BP=140/78; Joe a PCT tells the nurse he has
    heard Jack asking another Mr. Joy for his
    telephone cord because his was broken
    -1010 nurse ask Jack about the telephone
    cord and Jack denies that he ask Mr. Joy for
    his telephone cord; client interviewed about
    Jack’s request to borrow his telephone cord –
    client states that Jack did ask to borrow his
    telephone cord because Jacks was broken
    -1020 physician (Dr. Dan) notified: obtained
    orders for elopement risk, 1:1 sitter ; suicide

   Lorin Little is a 28 year old admitted with a      Nursing Note:
    diagnosis of paranoid schizophrenia and
    aggressive behavior. Lorin is uncooperative,
    and throws a chair across the room at
    another client. When the nurse attempts to
    encourage her to return to her room Lorin
    makes a fist and states that she will kill
    anyone who touches her.
   The following occurs:
    -1000 nurse calls for unit assistance and
    notifies Dr. Dan concerning Lorin’s behavior;
    Dr. Dan orders: Thorazine 50 mg IM stat
    and repeat with Thorazine 25 mg IM Q2H
    for aggressive behavior; elopement risk, 1:1
    -1005 unit security restrained client to
    administer 50 mg IM Thorazine in left
    deltoid; aggressive behavior toward security
    included attempts to bit, kick, and punch;
    escorted to room with 1:1 sitter; Lorin
    cursing and yelling at sitter
    -1015 Lorin is clam, cooperative and follows
    directions; 1:1 sitter inplace; security                            10
    returned to prior duties

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