Professional Documents
Culture Documents
A: Se comunico con el jefe del servico para notificar Called Dr Smith and he ordered blood cultures
X2, a CBC and a portable chest X-ray. After blood cultures were drawn, patient was given Tylenol at
1400.
R: By 1500 patient's temperature was 99.8 (oral). Lab and X-ray results are pending. Will continue to
monitor closely.
thought I had a link to a webpage on this but I can't find it in my files. DAR is a form of focus charting
and the DAR stands for Data-Action-Response. It ensures documentation that is based upon the
nursing process. Routine nursing tasks and assessment data is documented on flow sheets and check
lists.
Your focus is a nursing diagnosis, or in place of a nursing diagnosis you can use a problem, sign or
symptom (nausea, pain, etc), behavior, special need, an acute change in the patient's condition or a
significant event. Your progress note is written in the DAR form.
D (Data) - includes subjective and objective information the describes the focus.
A (Action) - includes immediate and future nursing actions based on your assessment of the
patient's condition and any changes to the care plan you deem necessary based on your evaluation.
Ineffective individual coping related to crisis situations, personal vulnerability, not adequate support system, work
overload, inadequate relaxation, not adequate coping methods, severe pain
Nursing Interventions :
• Approach the patient with a friendly and attentive. Take advantage of activities that can be taught.
• Assist patients in understanding the changes in the concept of body image.
• Advise the patient to express his feelings and discussion how the headaches that interfere with the work and
pleasures of this life.
• Ensure the impact of illness on sexual needs.
• Give information about the causes of headaches, handling, and expected results.
• Collaboration : Refer to counseling and / or family therapy or class assertiveness training sites as indicated.
Goals/Objectives
Short-Term Goal
Client will voluntarily spend time with staff and peers in dayroom activities within 1 week.
Long-Term Goal
These aids may assist client to function more independently, thereby increasing self-
esteem.
Outcome Criteria
1. Client initiates own self-care according to written schedule and willingly accepts
assistance as needed.
2. Client interacts with others in group activities, maintaining anxiety at minimal level in
response to difficulties with verbal communication.
Goals/Objectives
Short-Term Goal
Long-Term Goal
6. Ensure that smoking materials and other potentially harmful objects are stored outside
client's access. Client may harm self or others in disoriented, confused state.
7. Frequently orient client to reality and surroundings. Disorientation may endanger client
safety if he or she unknowingly wanders away from safe environment.
8. Monitor vital signs every 15 minutes initially and less frequently as acute symptoms
subside. Vital signs provide the most reliable information regarding client condition
and need for medication during acute detoxification period.
9. Follow medication regimen, as ordered by physician. Common medical intervention for
detoxification from the following substances includes
a. Alcohol. Chlordiazepoxide (Librium) is given orally every 4 to 8 hours in
decreasing doses until withdrawal is complete. In clients with liver disease,
accumulation of the longer-acting agents, such as chlordiazepoxide, may be
problematic, and the use of the shorter-acting benzodiazepine oxazepam (Serax)
is more appropriate. Some physicians may order anticonvulsant medication to be
used prophylactically; however, this is not a universal intervention. Multivitamin
therapy, in combination with daily thiamine (either orally or by injection), is a
common protocol.
b. Narcotics. Narcotic antagonists, such as naloxone (Narcan), nalorphine (Nalline),
or levallorphan (Lorfan), are administered intravenously for narcotic overdose.
Withdrawal is managed with rest and nutritional therapy. Substitution therapy
may be instituted to decrease withdrawal symptoms, with the use of
propoxyphene (Darvon) for weaker effects or methadone (Dolophine) for longer
effects.
c. Depressants. Substitution therapy may be instituted to decrease withdrawal
symptoms using a long-acting barbiturate, such as phenobarbital (Luminal). Some
physicians prescribe oxazepam as needed for objective symptoms, gradually
decreasing the dosage until the drug is discontinued.
d. Stimulants. Treatment of overdose is geared toward stabilization of vital signs.
Intravenous antihypertensives may be used, along with intravenous diazepam
(Valium) to control seizures. Chlordiazepoxide may be administered orally for the
first few days while the client is "crashing."
e. Hallucinogens and Cannabinols. Medications are normally not prescribed for
withdrawal from these substances. However, in the event of overdose, diazepam
or chlordiazepoxide may be given as needed to decrease agitation.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Client will be able to verbalize effects of [substance used] on the body after implementation of
teaching plan.
Long-Term Goal
Client will verbalize the importance of abstaining from use of [substance] in order to maintain
optimal wellness.
Outcome Criteria
DEPRESSIVE DISORDERS
Goals/Objectives
Short-Term Goal
Client will develop trusting relationship with nurse or counselor within reasonable period of
time.
Long-Term Goals
1. Client will voluntarily spend time with other clients and nurse or therapist in group
activities by discharge from treatment.
2. Client will refrain from using egocentric behaviors that offend others and discourage
relationships by discharge from treatment.
1. Spend time with client. This may mean just sitting in silence for a while. Your presence
may help improve client's perception of self as a worthwhile person.
2. Develop a therapeutic nurse-client relationship through frequent, brief contacts and an
accepting attitude. Show unconditional positive regard. Your presence, acceptance, and
conveyance of positive regard enhance the client's feelings of self-worth.
3. After client feels comfortable in a one-to-one relationship, encourage attendance in group
activities. May need to attend with client the first few times to offer support. Accept
client's decision to remove self from group situation if anxiety becomes too great. The
presence of a trusted individual provides emotional security for the client.
4. Verbally acknowledge client's absence from any group activities. Knowledge that his or
her absence was noticed may reinforce the client's feelings of self-worth.
5. Teach assertiveness techniques. Interactions with others may be negatively affected by
client's use of passive or aggressive behaviors. Knowledge of assertive techniques could
improve client's relationships with others.
6. Provide direct feedback about client's interactions with others. Do this in a
nonjudgmental manner. Help client learn how to respond more appropriately in
interactions with others. Teach client skills that may be used to approach others in a more
socially acceptable manner. Practice these skills through role play. Client may not realize
how he or she is being perceived by others. Direct feedback from a trusted individual
may help alter these behaviors in a positive manner. Practicing these skills in role play
facilitates their use in real situations.
7. The depressed client must have a lot of structure in his or her life because of impairment
in decision-making and problem-solving ability. Devise a plan of therapeutic activities
and provide client with a written time schedule. Remember: The client who is moderately
depressed feels best early in the day, whereas the severely depressed individual feels
better later in the day; choose these times for the client to participate in activities.
8. Provide positive reinforcement for client's voluntary interactions with others. Positive
reinforcement enhances self-esteem and encourages repetition of desirable behaviors.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Client will demonstrate use of relaxation techniques to maintain anxiety at manageable level
within 7 days.
Long-Term Goal
By discharge from treatment, client will be able to recognize events that precipitate anxiety and
intervene to prevent disabling behaviors.
1. Be available to stay with client. Remain calm and provide reassurance of safety. Client
safety and security are nursing priorities.
2. Help client identify situation that precipitated onset of anxiety symptoms. Client may be
unaware that emotional issues are related to symptoms of anxiety. Recognition may be
the first step in eliminating this maladaptive response.
3. Review client's methods of coping with similar situations in the past. Discuss ways in
which client may assume control over these situations. In seeking to create change, it
would be helpful for client to identify past responses and to determine whether they
were successful and whether they could be employed again. A sense of control reduces
feelings of powerlessness in a situation, ultimately decreasing anxiety. Client strengths
should be identified and used to his or her advantage.
4. Provide quiet environment. Reduce stimuli: low lighting, few people. Anxiety level may
be decreased in a calm atmosphere with few stimuli.
5. Administer antianxiety medications as ordered by physician, or request order if
necessary. Monitor client's response for effectiveness of the medication as well as for
adverse side effects. Antianxiety medications (e.g., diazepam, chlordiazepoxide,
alprazolam) provide relief from the immobilizing effects of anxiety and facilitate
client's cooperation with therapy.
6. Discuss with client signs of increasing anxiety and ways of intervening to maintain the
anxiety at a manageable level (e.g., exercise, walking, jogging, relaxation techniques).
Anxiety and tension can be reduced safely and with benefit to the client through
physical activities.
Outcome Criteria
1. Client is able to verbalize events that precipitate anxiety and to demonstrate techniques to
reduce anxiety.
2. Client is able to verbalize ways in which he or she may gain more control of the
environment and thereby reduce feelings of powerlessness.
INEFFECTIVE COPING
Definition: Inability to form a valid appraisal of the stressors, inadequate choices of practiced
responses, and/or inability to use available resources.
Goals/Objectives
Short-Term Goal
By the end of 1 week, client will comply with rules of therapy and refrain from manipulating
others to fulfill own desires.
Long-Term Goal
By discharge from treatment, client will identify, develop, and use socially acceptable coping
skills.
1. Discuss with client the rules of therapy and the consequences of noncompliance. Carry
out the consequences matter of factly if rules are broken. Negative consequences may
decrease manipulative behaviors.
2. Do not debate, argue, rationalize, or bargain with the client regarding limit setting on
manipulative behaviors. Ignoring these attempts may decrease manipulative behaviors.
Consistency among all staff members is vital if this intervention is to be successful.
3. Encourage discussion of angry feelings. Help client identify the true object of the
hostility. Provide physical outlets for healthy release of the hostile feelings (e.g.,
punching bags, pounding boards). Verbalizing feelings with a trusted individual may
help client work through unresolved issues. Physical exercise provides a safe and
effective means of releasing pent-up tension.
5. Help client recognize some aspects of his or her life over which a measure of control is
maintained. Recognition of personal control, however minimal, diminishes the feeling
of powerlessness and decreases the need for manipulation of others.
6. Identify the stressor that precipitated the maladaptive coping. If a major life change has
occurred, encourage client to express fears and feelings associated with the change.
Assist client through the problem-solving process:
a. Identify possible alternatives that indicate positive adaptation.
b. Discuss benefits and consequences of each alternative.
c. Select the most appropriate alternative.
d. Implement the alternative.
e. Evaluate the effectiveness of the alternative.
f. Recognize areas of limitation and make modifications. Request assistance with
this process, if needed.
7. Provide positive reinforcement for application of adaptive coping skills and evidence of
successful adjustment. Positive reinforcement enhances self-esteem and encourages
repetition of desirable behaviors.
Outcome Criteria
Goals/Objectives
Short-Term Goal
Client will verbalize understanding that physical symptoms interfere with role performance in
order to fill an unmet need.
Long-Term Goal
1. Determine client's usual role within the family system. Identify roles of other family
members. An accurate database is required in order to formulate appropriate plan of
care for the client.
3. Encourage client to discuss conflicts evident within the family system. Identify how
client and other family members have responded to this conflict. It is necessary to
identify specific stressors, as well as adaptive and maladaptive responses within the
system, before assistance can be provided in an effort to create change.
4. Help client identify the feelings associated with family conflict, the subsequent
exacerbation of physical symptoms, and the accompanying disabilities. Client may be
unaware of the relationship between physical symptoms and emotional problems. An
awareness of the correlation is the first step toward creating change.
5. Help client identify changes he or she would like to see within the family system.
6. Encourage family participation in the development of plans to effect positive change, and
work to resolve the conflict for which the client's sick role provides relief. Input from the
individuals who will be directly involved in the change will increase the likelihood of a
positive outcome.
7. Allow all family members’ input into the plan for change: knowledge of benefits and
consequences for each alternative, selection of appropriate alternatives, methods for
implementation of alternatives, formation of alternate plan in the event initial change is
unsuccessful. Family may require assistance with this problem-solving process.
8. Ensure that client has accurate perception of role expectations within the family system.
Use role playing to practice areas associated with client’s role that he or she perceives as
painful. Repetition through practice may help desensitize client to the anticipated
distress.
9. As client is able to see the relationship between exacerbation of physical symptoms and
existing conflict, discuss more adaptive coping strategies that may be used to prevent
interference with role performance during times of stress.
Outcome Criteria
"In the last 24 hrs urinary output has been diminishing. Pt has indicated that he feels as though he is
not emptying his bladder despite needing to void more frequently. This AM his bladder was distended
and he is unable to pass his urine. He is quite uncomfortable and anxious, and is requesting Tylenol
ES tab i for relief of a frontal headache. He is continent and successfully emptied his bowels yesterday.
His physician has just ordered a #12-10cc foley catheter to continuous drainage to be inserted
immediately to relieve urinary retention. VS: 168/92-88-20 Temp -36C "
Your data is going to be all of your subjective and objective data. I would start with the subjective
data and then move to the objective data because in that order it will show that you did an action
which is to assess. The whole note isn't going to follow the DAR format exactly from beginning to end
because you have several things going on here that each need their own intervention.
Basically this format is asking you to note your Assessment (subjective/objective info), your
Interventions/Action (what did you do once you assessed this pt?) and the the response you got
because of your intervention (an example of this would be to do another note about an hour later
reassessing your pt's pain score and the fact that you notified the doc).
I sure hope this helps. The more charting you do, the easier it will get.
DATA
ACTION
RESPONSE
Example........"Pt feels they are not emptying bladder feels need to void more frequently. Palpated
bladder, distension noted and pt not able to pass urine. Pt c/o being uncomfortalbe, anxious, pain.
Pain and HA 6/10 gave Tylenol ES. Pt continent of bowel. LBM (yesterday's date). VS: BP168/92 P88
R20 T36C. Dr Notified."
"Foley inserted. 12Fr 10 mL balloon to gravity. No pain during insertion Draining clear yellow urine.
1000 mL out. Reassessed pain. Now 1/10. Pt states "I feel so much better".
kay, This is what I've done.. tell me what you think. I left out the bowel stuff since he's continent and
we chart only things that are out of the ordinary.. I don't really think it needs to be on there.