10. pfe and docu basic

8/4/2019 10. PFE and Docu Basic

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Patient and Family Education

and Documentation


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Assessment checklist

Physical

Psycho-social

Mental-Spiritual Environmental

Diagnostic Results

Vital signs, initial

NURSING PROCESS

Progress Notes:

Focus charting

W/ DAR Format

Implementation

Medication sheet

Vital signs sheet

I.V. fluids sheet

I & O sheet

Other special forms * Kardex

* A.B.C.D.

* Maslows

Hierarcy

EVALUATE

GATHER DATA

ANALYZE DATA

IMPLEMENT PLAN


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Why patient and family education?

Many patients are not accustomed to IVtherapy.

He may be apprehensive.

He may be concerned that his conditionhas worsened.

Pediatric patients may even be more

afraid. Teaching will help the patient and his

family relax.


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Based on past experience

Assess patients previous experience, hisexpectations, knowledge of venipunctureand IV therapy.

Describe the procedure.Explain that fluids will come from a bag

through a tubing, then through the catheter

into his vein.Explain how long the catheter might stay in

place.


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The whole story

Give the patient as much as information aspossible.

Tell the patient that he may feel pain as the

needle goes in but will stop once the needle isin place.

Explain why IV therapy is needed.

Explain that fluids may feel cold at first.

Instruct to report any discomfort.

Explain activity restrictions.


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Easing anxiety

Give the patient time to express hisconcerns and fears.

Encourage the patient to use stress-reduction techniques.

Allow the patient and his family toparticipate in their care as much aspossible.


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But did they get it?

Be sure to evaluate how ell the patient andhis family understand your instruction.

Evaluate while youre teaching and whenyoure done.

Ask frequent questions and have themexplain or demonstrate what youvetaught.


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Dont forget the paperwork

Document all your teaching in the patientsrecords.

Note what you taught and how well thepatient understand it.


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What to document?

During initiation of IV therapy:

Size, length and type of device

Name of person inserting the device Date and time Site location Type of solution and any additives added Flow rate


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What to document?

During initiation of IV therapy:

Use of an electronic infusion device or othertype of flow controller

Complications Patient response Nursing interventions

Patient teaching, evidence of patientunderstanding


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What to document?

During maintenance of IV therapy:

Condition of the site

Site care provided Dressing changes

Tubing and solution changes

Teaching and evidence of patient understanding.


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What to document?

During termination of IV therapy: Date and time

Reason for discontinuing therapy

Assessment of site before and after venous accessdevice is removed

Complications

Patient reactions

Nursing interventions

Integrity of the venous access device on removal

Follow-up actions


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FORMS USED IN IV THERAPY

Patient and family education form

Infusion sheet

Medication sheet Multi-disciplinary plan of care

Multi-disciplinary progress notes

Hand-over checklist Blood transfusion monitoring sheet


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Sample DAR charting

08/20/08

6-2PM

8AM

8:10AM

8:15AM

For IVinsertion

D for IV insertion of D5NM 1L as ordered.

A assessed patient.

- explained the procedure and addressed patientsconcerns.

- materials prepared aseptically.

R IV line inserted; patient tolerated the procedurewell

- instructed patient on how to prevent catheterdislodgement.

- used materials discarded accordingly.

Raizzah T. Mansoura, RN


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References:

Nursing Standards on Intravenous Practice. Philippines: Association of NursingService Administrators of the Philippines, 2006.

I.V. Therapy Made Incredibly Easy. Philadelphia: Lippincott Williams & Wilkins,2006.

Just the Facts: I.V. Therapy. Lippincott Williams & Wilkins, 2005. RA 7164.

RA 9173. PRC-BON Resolution No. 08. PRC-BON Protocol Governing Special Training on the Administration of

Intravenous Injection for Registered Nurses. DOH Department Circular No. 100 Series of 1995. ANSAP Code of Ethics.

PRC-BON Resolution No. 220. Standards of Safe Nursing Practice. Philippine Nursing Law, Jurisprudence and Ethics. RA 7719. RA 9165. RA 9502.

10. pfe and docu basic

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