Patient and Family Education and Documentation

Assessment checklist

NURSING PROCESS
Progress Notes: Focus charting W/ DAR Format

Physical Psycho-social Mental-Spiritual Environmental

GATHER DATA

Diagnostic Results
Vital signs, initial

EVALUATE Implementation Medication sheet Vital signs sheet

ANALYZE DATA

Maslows
Hierarcy

* A.B.C.D.
IMPLEMENT PLAN

I.V. fluids sheet

I & O sheet

Other special forms

* Kardex

Why patient and family education?

Many patients are not accustomed to IV therapy. He may be apprehensive. He may be concerned that his condition has worsened. Pediatric patients may even be more afraid. Teaching will help the patient and his family relax.

Based on past experience

Assess patients previous experience, his expectations, knowledge of venipuncture and 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.

The whole story

Give the patient as much as information as possible. Tell the patient that he may feel pain as the needle goes in but will stop once the needle is in place. Explain why IV therapy is needed. Explain that fluids may feel cold at first. Instruct to report any discomfort. Explain activity restrictions.

Easing anxiety
Give the patient time to express his concerns and fears. Encourage the patient to use stressreduction techniques. Allow the patient and his family to participate in their care as much as possible.

But did they get it?

Be sure to evaluate how ell the patient and his family understand your instruction. Evaluate while youre teaching and when youre done. Ask frequent questions and have them explain or demonstrate what youve taught.

Dont forget the paperwork

Document all your teaching in the patients records. Note what you taught and how well the patient understand it.

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

What to document?
During initiation of IV therapy:
Use of an electronic infusion device or other type of flow controller Complications Patient response Nursing interventions Patient teaching, evidence of patient understanding

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.

What to document?
During termination of IV therapy:
Date and time Reason for discontinuing therapy Assessment of site before and after venous access device is removed Complications Patient reactions Nursing interventions Integrity of the venous access device on removal Follow-up actions

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

Sample DAR charting

08/20/08 6-2PM 8AM For IV insertion D for IV insertion of D5NM 1L as ordered. A assessed patient. - explained the procedure and addressed patients concerns. - materials prepared aseptically. R IV line inserted; patient tolerated the procedure well - instructed patient on how to prevent catheter dislodgement. - used materials discarded accordingly. Raizzah T. Mansoura, RN

8:10AM

8:15AM

References:

Nursing Standards on Intravenous Practice. Philippines: Association of Nursing Service 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.