Download *Instructions regarding where each item should be documented in

HINDS COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING
POST/PARTUM CLINICAL TOOL
*Instructions regarding where each item should be documented in DocuCare is explained below in “red”. Some
items will be listed in the Addendum notes (see attachment). *Sections from DocuCare that need to be “printed
out” and “brought to clinical” are noted in green. You may cut and paste the information into one Word document
if that will make it easier for you.
Demographic information will be collected when you first initiate the EHR. Make sure you input all information in
correctly the first time as you will not be able to go in and revise it. Once you have built your case, you will see the
“Patient Information” in the tabs listed below.
Client Initials
Age
Room
Date
Admit Date
Agency
Student
Admitting Diagnosis / Reason for Seeking Healthcare
Other Diagnosis
Other Health Problems
Past Surgeries and Dates:
This information will be charted under “Patient information” within the “Demographics” and “Current Visit”
tabs.
Diet at Home: Assessment – GI - Other
Activity Level: ADL -ADL Assessment Pre-pregnancy Wt. Addendum
Allergies & Type Reaction: Pt Info – Allergies Admit: Height Pt Info - Demographics Weight Pt Info - Demographics
LMP Notes – Nursing Note: Antepartum - Notes
EDD Notes – Nursing Note: Antepartum – Estimated date of conception
By dates/sono Notes – Nursing Note: Antepartum - Notes
Home Medications: MAR – Home Medications
Drug
Dose
Frequency
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Time/Date
Vital Signs
B/P
Vital Signs
TPR
Vital Signs
Pain 0-10
Assessment – Pain Scale
Intake
I/O
Output
I/O
Nursing Procedures Required for this Client
Addendum
Discharge Needs / Referrals Relative to Current Health
Status
F/U Appt. Notes – Discharge Planning
Housing Needs Notes – Discharge Planning
Car Seats Notes – Discharge Planning
Teaching / Learning Needs of Client and/or Primary
Caregiver:
Self Care Notes – Discharge Planning
Newborn Care:
Elimination Notes – Discharge Planning
Feeding Notes – Discharge Planning
Safety Notes – Discharge Planning
Pertinent Lab Data: Diagnostics – Add new lab
(Significance of client results should documents in parenthesis after you fill in the client’s “Results”)
Date
Test
Results
Normal Range
Significance of Results to Client’s Diagnosis
Blood Type
CBC: Hgb/Hct
Rh
Antibody Titer
VDRL or RPr
HIV
Rubella
Hep B
Toxicology
U/A:Protein Glucose
Baby’s Blood Type
Pertinent Diagnostic Studies / Procedures: Diagnostics – Add new lab
(Significance of client results should documents in parenthesis after you fill in the client’s “Result”)
Date
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Test
Results
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Significance of results to Client’s Diagnosis
ASSESSMENT DATA
Health Perception – Health management Pattern
Client’s Description of Current Health Problems __Pt Info – Current Visit – Primary Admitting
Diagnosis
Past Health Problems __ Pt Info – Previous Visit - Diagnosis_____________________________
Description of General Health Status _____Complete “Assessment” Tabs_______________________
Immunizations (Diagnostics – Add new immunization): Flu ___ Pneumonia ___ Tetanus ___ Rubella ___
Allergies: Type Reaction _____Pt Info - Allergy__________________ Treatment ____ Pt Info - Allergy _
Supplements / Herbal Remedies: ________MAR – Home Medications___________________________
‘
Addendum (all of the following)
Health Promotion Activities / Practices:
Exercise _________________ Prenatal Care ________________________
Compliance with Prescribed Therapeutic Regimen (medications, diet, and exercise) ____________
Other ____________________________________________________________________________
Health Promotion Screening Tests:
Last Mammogram: ___ Last Pap Smear ____ Breast Self Exam ____
Exposure to Tetrogens/Communicable Disease ________________________________
Risk Factors for Impaired Health Management ________________________________________
Use of Alcohol, Drugs (including OTC), and Tobacco ____________________________
Nutritional – Metabolic Pattern
General Appearance __________Complete Assessment___________________________________
Prescribed Diet __________Assessment – GI – Diet Type______________________________
Understanding of Prescribed Diet ______________ Assessment – GI – Other_____________________
Interferences with Usual Dietary and Fluid Pattern _________ Assessment – GI – Other (if applicable)__
Daily Food and Fluid Intake __________ADLs – Diet Consumption______________________________
Food Intolerances __________ Assessment – GI – Other (if applicable)_________________________
Condition of Skin: Assessment – Integumentary – Record Skin
Intact _________________ Color ______________ Texture ___________________
Temperature _____________ Turgor _______________ Moisture ________________
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NURSING
DIAGNOSIS
Nursing diagnosis
will go under the
“Other”/”Notes” tab
of any of the
applicable sections
of the “Assessment”
tab in DocuCare.
Any abnormal
assessment finding
that is document on
the addendum, a
nursing diagnosis will
needed to be charted
there.
NURSING
DIAGNOSIS
ASSESSMENT DATA
Nutritional Metabolic – cont’d Assessment – Integumentary – Record new site
Indicate on the figure by number any skin alterations.
1. Pressure area / decubiti
Stage _________________ Size __________________
2. Abrasions / lacerations
3. Surgical Incisions / Scars
4. Hematoma / Ecchymosis / Petechiae
5. Rash / Lesions
6. Amputation
7. Dressings / Type ________________________________
8. Drains / Type ___ Assessment – GI – Gastric Tube________________________________
9. Nodules
10. Ostomy / Type ________ Assessment – GI – Ostomy__________________________
Breasts:
□ soft
□ firm
□ redness
Nipples:
□ flat
□
inverted
□ cracked
Lochia:
□ rubra
□ serosa
□ alba
Fundus:
□ firm
□ boggy
____ location
Incision:
□ redness
Perineum:
□ redness
□
swelling
□
swelling
□
approximated
□
approximated
Dressing:
□ dry
□ intact
□ wet
Feeding:
□ breast
□ bottle
□ bra on
□ tender
□
blistered
□
amount
□
bruising
□ edema
□ bra off
Notes – Nursing note:
Postpartum
Notes – Nursing note:
Postpartum
Notes – Nursing note:
Postpartum
Notes – Nursing note:
Postpartum
Assessment – Integumentary –
Record new site
Assessment – GU – Genitalia
Exam
Assessment – Integumentary –
Record new site
Notes – Nursing note:
Postpartum
Conditions affecting Skin/Fluid/Nutritional status (N&V, diarrhea, diuresis, difficulty chewing, swallowing,
taste, smell, etc) ________Assessment – GI
_________________________________________________
Medications Affecting Skin/Fluid/Nutritional Status ______MAR – Select RX to add – Provider Notes__
Lab Diagnostic Tests r/t Skin/Fluid/Nutritional Status _______ Diagnostics – Add new lab - Significance
of client results should documents in parenthesis after you fill in the client’s “Results”
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ASSESSMENT DATA
Activity – Exercise Pattern
Usual Daily Activities _________ADLs – Notes_________________________________________
Usual Pattern of Exercise ___________ ADLs – Notes___________________________________
History of Cardiac, Respiratory, &/or Activity/Mobility Problems Assessment (of applicable section) –
Other/Notes
Activity Tolerance ____ADLs – Notes (if applicable)_____________________________________
Usual Ability to Perform ADL’s ____________ ADLs – Notes________________________
Effect of IPregnancy/Delivery on ADL’s ______________ ADLs – Notes (if applicable)________
Musculoskeletal Assessment: Gait ___________ Posture ____________ Tone ___________
Limitation (location) ________________________________
Respiratory Assessment:
Breath Sounds (describe) ______________________ Pattern and Rate ________________
Use of Accessory Muscles _____________ Cough __________ Sputum _______________
O2 use - @ _________________ liters / min via ___________________ O2 sat _________
Other Aids (hand held nebulizers, incentive spirometer) _______________________
Cardiovascular Assessment:
Edema ___________________ Location ______________________ Grade _____________
Rate and Rhythm: Radial ____________ Apical _______________ Murmurs __________
Peripheral Pulses Assessment: ___________________________________________________
Evidence of Thrombus Formation Assessment – Cardiovascular – Other:
Upper Extremities: L __ R __
Lower Extremities: L __ R __
Homan’s Sign: L _N/A_ R_N/A_
Pain / Discomfort _______Assessment – Pain Scale__________________________________
Conditions Affecting Activity – Exercise Pattern ________ ADLs – Notes (if applicable)______
Medications Affecting Activity – Exercise Pattern _______ ADLs – Notes (if applicable)______
Lab / Diagnostic Tests R/T Activity – Rest Pattern Diagnostics – Add new lab - Significance of
client results should documents in parenthesis after you fill in the client’s “Results”
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NURSING DIAGNOSIS
ASSESSMENT DATE
NURSING DIAGNOSIS
Sleep – Rest Pattern - Addendum
Usual Pattern of Sleep _______________________________ Quality ______________________
Difficulty Falling Asleep _________Sleep through the Night __________ Use of Sleep Aids _________
Signs of Sleep Deprivation (yawning, irritability) _________________________________________
Conditions Affecting Sleep / Rest Patterns _____________________________________________
Medications Affecting Sleep / Rest Patterns MAR – Select RX to add – Provider Notes
Lab / Diagnostic Tests R/T Sleep / Rest Patterns Diagnostics – Add new lab - Significance of client
results should documents in parenthesis after you fill in the client’s “Results”
Cognitive – Perceptual Pattern Addendum
Problems with: Vision _________________________ Hearing _____________________________
Aids for vision __________________________ Aids for Hearing ____________________________
Pain Perception ________________________________________________________________
Balance ___________ Coordination _________ Pupils __________ Paralysis ____________
Speech _________________
Reflexes:
□ Normal
□ Hyper reflexia
Oriented:
□ Person
□ Place □ Time
□ Hyporeflexia
□ Absent
Level of Concentration _______________
Confusion _________________________ Ability to Follow Commands _______________________
Comprehension _____________________ Decision Making Ability __________________________
Ability to Read and Write _______________ Highest Level of Education Completed ______________
Cognitive / Perceptual Factors Interfering with Safety ______________________________________
Conditions Affecting Cognitive / Perceptual Patterns
_________________________________________
Medications Affecting Cognitive / Perceptual Patterns MAR – Select RX to add – Provider Notes
Lab / Diagnostic Test R/T Cognitive / Perceptual Patterns Diagnostics – Add new lab - Significance
of client results should documents in parenthesis after you fill in the client’s “Results”
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ASSESSMENT DATA
Self Perception – Self Concept Patterns Addendum
Chronological Stage of Growth & Development and Primary Development Task R/T this Stage
__________________________________________________________________________________________
Is Client achieving Expected Development Task? □ Yes
□ No, Explain _____________________________
Relevant Ethnic / Cultural Factors _______________________________________________________________
Eye Contact __________________ Affect ______________________ Mood ___________________________
Body Posture _______________________ Grooming ______________________ Voice Tone _____________
Perception of: Body Image ___________________________ Self ___________________________________
Beliefs About How Others Regard Them _________________________________________________________
Feelings About Being a Parent _________________________________________________________________
Conditions Affecting Self Perception – Self Concept ________________________________________________
Medications Affecting Self Perception – Self Concept MAR – Select RX to add – Provider Notes
Role – Relationship Pattern Addendum
Roles (family / social) _______________________________________________________________________
Living Arrangements ________________________________ Members of Household ____________________
Family Support ____________________________________ Occupation ______________________________
Free from Apparent Abuse ____________________________________________________________________
Conditions Affecting Acquiring Parenting Role ____________________________________________________
Conditions Affecting Role – Relationship ________________________________________________________
Medications Affecting Role – Relationship MAR – Select RX to add – Provider Notes
Sexuality – Reproductive Pattern Addendum
Effect of Illness / hospitalization on sexuality ____________________________________________________
Contraceptive Plans: ____________________________________ Where Obtaining ___________________
Past Contraceptive Use: ___________________ Successful ____________ Unsuccessful ________________
Conditions Affecting Sexuality / Reproductive ____________________________________________________
Medications Affecting Sexuality / Reproductive MAR – Select RX to add – Provider Notes
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NURSING
DIAGNOSIS
ASSESSMENT DATA
Elimination Patterns Addendum
Usual Bowel Habits
Frequency ________________ Color _________ Amount ____________ Consistency ________________
Pain / Discomfort ___________________ Continence ____________ Date of Last BM __________________
Use of Laxatives or Other Aids _______________________________________________________________
Bowel Sounds: Present _______________________ Characteristics ________________________________
Usual Bladder Habits
Frequency ________________ Amount _____________ Color _____________ Distention ______________
Any Difficulty? _________ If so, Describe _____________________________________________________
Catheter _________________________________________ Type _________________________________
Abdomen:
Contour ________________ Striae ________________________ Umbilicus __________________________
Distention ________________ Incision ________________________ Dressing ________________________
Lesions / Scars __________________________________________________________________________
Conditions of Genitalia, Rectum, and Perineal Area _________________________________________________
Swelling _________________ Ice Packs ____________________ Sitz Baths ________________________
Lesions ___________________ Discharge ____________________ Lochia __________________________
Episiotomy _____________________ Treatments: □ Ice Pack □ Heat Lamp □ Sitz Bath
Ability to Toilet Self _________________________________________________________________________
Conditions Affecting Elimination ________________________________________________________________
Medications Affecting Elimination MAR – Select RX to add – Provider Notes
Lab / Diagnostic Tests R/T Elimination Diagnostics – Add new lab - Significance of client results should
documents in parenthesis after you fill in the client’s “Results”
Coping / Stress Tolerance Pattern Addendum
Coping Techniques / Behaviors _______________________________________________________________
Stress Tolerance ___________________________________________________________________________
Anxiety __________________________________________________________________________________
Available Support Systems ___________________________________________________________________
Conditions Affecting Coping / Stress Tolerance Patterns ____________________________________________
Medications Affecting Coping / Stress Tolerance Patterns MAR – Select RX to add – Provider Notes
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NURSING
DIAGNOSIS
ASSESSMENT DATA
NURSING
DIAGNOSIS
Value / Belief Pattern Addendum
Cultural / Ethnic Beliefs / Practices __________________________________________________________
Religious Affiliation / Practices ______________________________________________________________
Importance of Religion / Spirituality __________________________________________________________
Religious / Cultural Requests During Care ____________________________________________________
Perception of Quality of Life ________________________________________________________________
Conditions Affecting Value / Belief Pattern ____________________________________________________
Addendum
Infant: Sex M ________ / F ________ Weight ________ Apgar @ 1 min _____________ Apgar @ 5 min
_____________
If < 10 reason ___________________________________ Remarks _________________________________________
Current Medications
*Enter each medication on the MAR tab. (AFTER YOU ENTER THE MEDICATION, CLICK THE GREEN
WIDGET FOR INFORMATION ON THE DRUG. PRINT AND BRING PERTINENT DRUG INFORMATION
TO CLINICAL).
Name of Drug
Trade/Generic
Classification
Expected
Therapeutic
Effect
(Action)
Reason
medication
given to
client
DosageRoute-Time of
AdminFrequency
Common
Side
Effects
Contraindications
Contingencies/
Common
Nursing
Actions
IV therapy is addressed under the ‘Assessment’ tab in the “Vascular access” section.
You can also add IV fluids to MAR.
IV Therapy: 1.
Rate:
Rationale for this Type IV Therapy:
IV Access/Site:
Start Date:
Date of Next IV Site Change:
IV Therapy: 2.
IV Access/Site:
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Rate:
Start Date:
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Rationale for this Type IV Therapy:
Date of Next IV Site Change:
Expected
Therapeutic
Outcome
Patient
Education
Needs
Care Plans
*The top 3 nursing diagnoses will be addressed under the “Nursing Dx” tab. Don’t forget to individualize the care
plan to fit “your patient.” List and number your rationale for each intervention that you select. You must be able
to explain/support your reason for choosing each diagnosis and be able to clearly discuss the care plan items.
(PRINT AND BRING CARE PLANS TO CLINICAL.)
Priority Problem
Statement / Nursing
Diagnoses/CP’s
(numerically listed in
Evaluation of Outcomes
Outcome Identification /
Family Outcomes
Nursing Interventions
Rationale for
Interventions
(including appropriate
evaluative statements)
order of priority)
Mini-Form
*Students will complete a mini-form “only” if they have to pick up a second patient on Tuesday because their
patient from Monday went home or was transferred, etc. (This mini-form is not addressed in DocuCare. If you
need to complete a mini-form for a 2nd patient, you will submit it in Canvas).
Nursing 2139 Mini-Form
Student Name:________________________________________
Room #__________Client Initials:____________________________________Age/Race/Sex________________________
Admission Date: _________________________Activity Level:________________________________________________
Medical Diagnosis: Principle:______________________ Treatments/Special orders:_____________________________
Other:________________________
_____________________________
Other Health Problems:__________________________________________Surgery/Date:__________________________
Allergies:____________________Diet:_____________________Lab/X-Ray/Other (TBD)__________________________
Medications (Include times to be given)
PO Meds/Time
IM/SC Meds/Time
IVPB Meds/Rate/Time
IVP Meds. Rate/Time
Priority Nursing Dx (3)
IV Therapy
Due Date for
1.
IV Fluids:
Site Chg:________________.
2.
Rate:
3.
Access Device:
Dressing Chg:_________________
Tubing Chg_________________
Journal (CAPC)
Journal entries will be documented in the “notes” section with the Addendum information in DocuCare. Do a
journal entry for each day of care.
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