PROBLEM-PROBLEM-ORIENTED ORIENTED CHARTINGCHARTING

MR. HARLEY L. DELA CRUZ, RN, MR. HARLEY L. DELA CRUZ, RN, MANMAN

LECTURERLECTURER

PROBLEM-ORIENTED PROBLEM-ORIENTED MEDICAL RECORD (POMR)MEDICAL RECORD (POMR) Introduced in 1969 by LAWRENCE WEED Introduced in 1969 by LAWRENCE WEED

CASE WESTERN RESERVE UNIVERSITYCASE WESTERN RESERVE UNIVERSITY Data are recorded and arranged according Data are recorded and arranged according

to the source of informationto the source of information The record integrates all data about the The record integrates all data about the

problem, gathered by the members of the problem, gathered by the members of the health teamhealth team

The focus of POMR documentation is on The focus of POMR documentation is on the client’s problem, with a structured, the client’s problem, with a structured, logical format to narrative charting called logical format to narrative charting called SOPIE.SOPIE.

FOUR BASIC FOUR BASIC COMPONENTS OF POMRCOMPONENTS OF POMR

1.1. Database. Contains all initial information Database. Contains all initial information about the patient.about the patient.

2.2. Problem list. Contains all aspects of the Problem list. Contains all aspects of the person’s life requiring health care.person’s life requiring health care.

3.3. Initial list of orders or care plans.Initial list of orders or care plans.4.4. Progress notes:Progress notes: a. Nurse’s or narrative notes (SOPIE a. Nurse’s or narrative notes (SOPIE

FORMAT)FORMAT) b. Flow sheetsb. Flow sheets c. Discharge notes or referral c. Discharge notes or referral

summariessummaries

SOPIE CHARTINGSOPIE CHARTING S: Subjective Data- what the client or S: Subjective Data- what the client or

family statesfamily states O: Objective Data- what is inspected or O: Objective Data- what is inspected or

observedobserved A: Assessment- conclusion reached on the A: Assessment- conclusion reached on the

basis of data formulated as client basis of data formulated as client problems or nursing diagnosesproblems or nursing diagnoses

P: Planning- actions to be taken to relieve P: Planning- actions to be taken to relieve client’s problemclient’s problem

I: Intervention- measures to achieve an I: Intervention- measures to achieve an expected outcomeexpected outcome

E: evaluation- effectiveness of interventionE: evaluation- effectiveness of intervention

SUBJECTIVE DATASUBJECTIVE DATA

SUBJECTIVE DATA:(SYMPTOMS) ARE INFORMATION FROM THE CLIENT’S (SOMETIMES FAMILY’S) POINT OF VIEW AND INCLUDE FEELINGS, PERCEPTIONS, AND CONCERNS.

THE PRIMARY METHOD OF COLLECTING SUBJECTIVE DATA IS THE INTERVIEW and OBSEVATION. SECONDARY SOURCES ARE FROM FAMILY, SIGNIFICANT OTHERS, PATIENT’S RECORD/CHART, OTHER HEALTH TEAM MEMBERS AND RELATED LITERATURES.

EXAMPLE:”It happened about an hour ago when my headache got worse. Now I am nauseated and dizzy,”as verbalized by the client.

•headache, nausea, dizziness, pain, DOB, nervousness, vertigo, tinnitus etc.

OBJECTIVE DATAOBJECTIVE DATA

OBJECTIVE DATAOBJECTIVE DATA:(SIGN) ARE OBSERVABLE :(SIGN) ARE OBSERVABLE AND MEASURABLE INFORMATION THAT IS AND MEASURABLE INFORMATION THAT IS OBTAINED THROUGH BOTH STANDARD OBTAINED THROUGH BOTH STANDARD ASSESSMENT TECHNIQUES AND THE ASSESSMENT TECHNIQUES AND THE RESULTS OF LABORATORY AND RESULTS OF LABORATORY AND DIAGNOSTIC TESTING.DIAGNOSTIC TESTING.

EXAMPLEEXAMPLE:TEMPERATURE: 99ºF/axilla,PULSE :TEMPERATURE: 99ºF/axilla,PULSE RATE:100 beats/min., RESPIRATION: 28 RATE:100 beats/min., RESPIRATION: 28 breaths/min., BLOOD PRESSURE: 150/90 mmHg, breaths/min., BLOOD PRESSURE: 150/90 mmHg, cannot move left arm, flushed face, face grimace, cannot move left arm, flushed face, face grimace, vomiting, rales on both lung fields, gait,pallor,skin vomiting, rales on both lung fields, gait,pallor,skin lesions, lung sounds diaphoresis,goose-fleshed skin lesions, lung sounds diaphoresis,goose-fleshed skin etc. etc.

ASSESSMENTASSESSMENT

ACTUAL NURSING DIAGNOSISACTUAL NURSING DIAGNOSIS- - indicates that a problem exists and is indicates that a problem exists and is composed of the diagnostic label, related composed of the diagnostic label, related factors and signs and symptomsfactors and signs and symptoms

Example: Example: Fluid volume deficit related to nausea and Fluid volume deficit related to nausea and vomiting as manifested by dry skin and mucous vomiting as manifested by dry skin and mucous membranes and decreased oral intake of fluidsmembranes and decreased oral intake of fluids

POTENTIAL NURSING DIAGNOSIS OR RISK NURSING DIAGNOSIS- indicates that a problem does not yet exist but special risk factors are present.Example: Risk for infection related to presence of invasive lines(IV line and indwelling catheter)

POSSIBLE NURSING DIAGNOSISPOSSIBLE NURSING DIAGNOSIS- - indicates a situation in which a problem indicates a situation in which a problem could arise unless preventive action is could arise unless preventive action is taken.taken.

Example: Example: Possible imbalanced nutrition: less than body Possible imbalanced nutrition: less than body requirements related to insufficient oral intake.requirements related to insufficient oral intake.

APPROVED NANDA(North American Nursing Diagnosis APPROVED NANDA(North American Nursing Diagnosis Association) DIAGNOSTIC CATEGORIESAssociation) DIAGNOSTIC CATEGORIES

OXYGEN NEEDS-IMPAIRED GAS EXCHANGE, INEFFECTIVE AIRWAY CLEARANCE, INEFFECTIVE BREATHING PATTERN, POTENTIAL FOR ASPIRATION

TEMPERATURE MAINTENANCE-POTENTIAL ALTERED BODY TEMPERATURE, HYPOTHERMIA, HYPERTHERMIA, INEFFECTIVE THERMOREGULATION

NUTRITIONAL AND FLUID NEEDS- ALTERED NUTRITION:LESS THAN BODY REQUIREMENTS, FLUID VOLUME DEFICIT-ACTUAL POTENTIAL, FLUID VOLUME EXCESS, IMPAIRED SWALLOWING

ELIMINATION NEEDS-CONSTIPATION, DIARRHEA, BOWEL INCONTINENCE, URINARY RETENTION, TOILETING SELF-CARE DEFICIT, STRESS INCONTINENCE

REST AND SLEEP NEEDS-FATIGUE, SLEEP PATTERN DISTURBANCE

THE NEED FOR PAIN AVOIDANCE-PAIN, CHRONIC PAIN

SEXUAL NEEDS-SEXUAL DYSFUNCTION, ALTERED SEXUAL PATTERN

STIMULATION NEEDSSTIMULATION NEEDS- ACTIVITY INTOLERANCE, POTENTIAL - ACTIVITY INTOLERANCE, POTENTIAL ACTIVITY INTOLERANCE, IMPAIRED PHYSICAL MOBILITY, ACTIVITY INTOLERANCE, IMPAIRED PHYSICAL MOBILITY, SENSORY/PERCEPTUAL ALTERATIONS-SPECIFY AS VISUAL, SENSORY/PERCEPTUAL ALTERATIONS-SPECIFY AS VISUAL, AUDITORY KINESTHETIC, GUSTATORY, TACTILE, OLFACTORYAUDITORY KINESTHETIC, GUSTATORY, TACTILE, OLFACTORY

SAFETY AND SECURITY NEEDSSAFETY AND SECURITY NEEDS- POTENTIAL FOR INFECTION, - POTENTIAL FOR INFECTION, POTENTIAL FOR INJURY, POTENTIAL FOR POISONING. POTENTIAL POTENTIAL FOR INJURY, POTENTIAL FOR POISONING. POTENTIAL FOR IMPAIRED TISSUE INTEGRITY, IMPAIRED SKIN INTEGRITY, FOR IMPAIRED TISSUE INTEGRITY, IMPAIRED SKIN INTEGRITY, ANXIETY, FEAR, KNOELEDGE DEFICIT, INEFFECTIVE INDIVIADUAL ANXIETY, FEAR, KNOELEDGE DEFICIT, INEFFECTIVE INDIVIADUAL COPINGCOPING

LOVE AND BELONGING NEEDSLOVE AND BELONGING NEEDS- IMPAIRED SOCIAL INTERACTION, - IMPAIRED SOCIAL INTERACTION, ALTERED PARENTING, PARENTAL ROLE CONFLICTALTERED PARENTING, PARENTAL ROLE CONFLICT

SPIRITUAL NEEDSSPIRITUAL NEEDS- SPIRITUAL DISTRESS- SPIRITUAL DISTRESS

SELF ESTEEM NEEDSSELF ESTEEM NEEDS-BODY IMAGE DISTURBANCE, -BODY IMAGE DISTURBANCE, DRESSING/HYGIENE SELF-CARE DEFICIT, SELF-ESTEEM DRESSING/HYGIENE SELF-CARE DEFICIT, SELF-ESTEEM DISTURBANCE,PERSONAL IDENTITY DISTURBANCE, DISTURBANCE,PERSONAL IDENTITY DISTURBANCE, POWERLESSNESS, DEFENSIVE COPINGPOWERLESSNESS, DEFENSIVE COPING

SELF-ACTUALIZATION NEEDSSELF-ACTUALIZATION NEEDS-IMPAIRED ADJUSTMENT, ALTERED -IMPAIRED ADJUSTMENT, ALTERED GROWTH DEVELOPMENT, HEALTH SEEKING BEHAVIORGROWTH DEVELOPMENT, HEALTH SEEKING BEHAVIOR

ORGANIZED BY HUMAN RESPONSE PATTERNORGANIZED BY HUMAN RESPONSE PATTERN

PATTERN 1:PATTERN 1:EXCHANGINGEXCHANGING-ALTERED NUTRITION: MORE THAN/LESS -ALTERED NUTRITION: MORE THAN/LESS THAN BODY REQUIREMENTS, POTENTIAL FOR INFECTION, THAN BODY REQUIREMENTS, POTENTIAL FOR INFECTION, DIARRHEA, FLUID VOLUME DEFICIT, IMPAIRED GAS EXCHANGE, DIARRHEA, FLUID VOLUME DEFICIT, IMPAIRED GAS EXCHANGE, POTENTIAL FOR INJURY, IMPAIRED SKIN INTEGRITYPOTENTIAL FOR INJURY, IMPAIRED SKIN INTEGRITY

PATTERN 2: PATTERN 2: COMMUNICATINGCOMMUNICATING: IMPAIRED VERBAL COMMUNICATION: IMPAIRED VERBAL COMMUNICATION

PATTERN 3: PATTERN 3: RELATINGRELATING- IMPAIRED SOCIAL INTERACTION, ALTERED - IMPAIRED SOCIAL INTERACTION, ALTERED PARENTING, SEXUAL DYSFUNCTION, PARENTAL ROLE CONFLICTPARENTING, SEXUAL DYSFUNCTION, PARENTAL ROLE CONFLICT

PATTERN 4: PATTERN 4: VALUINGVALUING- SPIRITUAL DISTRESS- SPIRITUAL DISTRESS

APPROVED NANDA(North American Nursing Diagnosis Association) DIAGNOSTIC CATEGORIES

PATTERN 5: PATTERN 5: CHOOSINGCHOOSING- INEFFECTIVE INDIVIDUAL COPING, IMPAIRED - INEFFECTIVE INDIVIDUAL COPING, IMPAIRED ADJUSTMENT, INEFFECTIVE DENIAL, NONCOMPLIANCEADJUSTMENT, INEFFECTIVE DENIAL, NONCOMPLIANCE

PATTERN 6: PATTERN 6: MOVING-MOVING-IMPAIRED PHYSICAL MOBILITY, ACTIVITY IMPAIRED PHYSICAL MOBILITY, ACTIVITY INTOLERANCE, FATIGUE, SLEEP PATTERN DISTURBANCE, INTOLERANCE, FATIGUE, SLEEP PATTERN DISTURBANCE, IMPAIRED SWALLOWING, HYGIENE/DRESSING SELF-CARE DEFICIT, IMPAIRED SWALLOWING, HYGIENE/DRESSING SELF-CARE DEFICIT, TOILETING SELF-CARE DEFICIT, ALTERED GROWTH AND TOILETING SELF-CARE DEFICIT, ALTERED GROWTH AND DEVELOPMENTDEVELOPMENT

PATTERN 7: PATTERN 7: PERCEIVINGPERCEIVING- BODY IMAGE DISTURBANCE, SELF ESTEEM - BODY IMAGE DISTURBANCE, SELF ESTEEM DISTURBANCE, PESONALITY IDENTITY DISTURBANCE, DISTURBANCE, PESONALITY IDENTITY DISTURBANCE, SENSORY/PERCEPTUAL ALTERATIONS, HOPELESS NESS, SENSORY/PERCEPTUAL ALTERATIONS, HOPELESS NESS, POWERLESSNESSPOWERLESSNESS

PATTERN 8: PATTERN 8: KNOWINGKNOWING- KNOWLEDGE D DEFICIT-SPECIFY, ALTERED - KNOWLEDGE D DEFICIT-SPECIFY, ALTERED THOUGHT PROCESSESSTHOUGHT PROCESSESS

PATTERN 9: PATTERN 9: FEELING-PAINFEELING-PAIN, CHRONIC PAIN, DYSFUNCTIONAL , CHRONIC PAIN, DYSFUNCTIONAL GRIEVING, POTENTIAL FOR VIOLENCE, POST TRAUMA RESPONSE, GRIEVING, POTENTIAL FOR VIOLENCE, POST TRAUMA RESPONSE, RAPE-TRAUMA SYNDROME, ANXIETY, FEARRAPE-TRAUMA SYNDROME, ANXIETY, FEAR

PLANNINGPLANNING

OUTCOME OUTCOME IDENTIFICATION AND IDENTIFICATION AND

PLANNINGPLANNINGPlanning involves developing a proposed Planning involves developing a proposed course of action in regard to the client’s course of action in regard to the client’s health status. health status.

The The words goals and outcomes are both words goals and outcomes are both used to describe expectationsused to describe expectations of what is of what is to be achieved as a result of nursing to be achieved as a result of nursing actions. Goals and outcomes are actions. Goals and outcomes are measures for determining client measures for determining client progress.progress.

PLANNING

TYPES OF SPECIFIC OBJECTIVES:SHORT TERM OBJECTIVES-identify outcome in patient's status or behavior that can be achieve in a matter of hours or days.Example: The patient’s respiration will decrease from 40 breaths/min to below 30 breaths/min within 1 hour. Return of bowel sounds within 12 hours postop The patient’s temp. will decrease from 38.5ºC to 37.5ºC after 1 hour of nursing intervention. After 2 hours of nursing intervention, patient will verbalize pain rate from 6(moderate) to 3(minimal)or below based on 1-10 pain rating scale(1-3=minimal; 4-7=moderate and 8-10=severe).

LONG TERM OBJECTIVESLONG TERM OBJECTIVES-a statement that outlines the -a statement that outlines the desired resolution of the nursing diagnosis over a longer desired resolution of the nursing diagnosis over a longer period of time, usually weeks or months. period of time, usually weeks or months.

Example: Self-care of colostomy 1 month after surgeryExample: Self-care of colostomy 1 month after surgery

Patient to state no longer afraid of having severe Patient to state no longer afraid of having severe pain during during terminal illness from cancer 1 week on IV pain during during terminal illness from cancer 1 week on IV morphine.morphine.

Reestablishment of patient’s usual bowel elimination Reestablishment of patient’s usual bowel elimination patterns in 2 months.patterns in 2 months.

Breastfeeding 10-15 min/breast, every 2-5 hours, Breastfeeding 10-15 min/breast, every 2-5 hours, within e weeks after delivery.within e weeks after delivery.

IMPLEMENTATIONIMPLEMENTATION

IMPLEMENTATIONIMPLEMENTATIONNURSING INTERVENTION/ IMPLEMENTATIONNURSING INTERVENTION/ IMPLEMENTATION--

INVOLVES THE EXECUTION OF THE NURSING INVOLVES THE EXECUTION OF THE NURSING CARE PLAN DERIVED DURING PLANNNG OF CARE PLAN DERIVED DURING PLANNNG OF CARE.CARE.

3 CATEGORIES OF NURSING INTERVENTIONS3 CATEGORIES OF NURSING INTERVENTIONS

Independent nursing interventionsIndependent nursing interventions- are nursing actions that - are nursing actions that are initiated by the nurse and do not require direction or a are initiated by the nurse and do not require direction or a order from another health care professional.order from another health care professional.

Example: positioning of client, assessment, provide Example: positioning of client, assessment, provide appropriate ventilation, providing appropriate milieu to appropriate ventilation, providing appropriate milieu to promote rest and sleeppromote rest and sleep

Dependent nursing interventionsDependent nursing interventions-are nursing actions that -are nursing actions that require an order from a physician or another health care require an order from a physician or another health care professional.professional.

Example: administration of specific medication prescribed by Example: administration of specific medication prescribed by the physician.the physician.

Interdependent nursing interventionsInterdependent nursing interventions: are nursing actions that : are nursing actions that are implemented in a collaborative manner by the nurse in are implemented in a collaborative manner by the nurse in conjunction with other health care professionalsconjunction with other health care professionals

Example: assisting client to perform an exercise taught by the Example: assisting client to perform an exercise taught by the physical therapistphysical therapist

EVALUATIONEVALUATION

EVALUATIONEVALUATIONEVALUATION-EVALUATION-involves determining whether the involves determining whether the

client objectives of care have been met, partially client objectives of care have been met, partially meet or not met.Evaluation involves the meet or not met.Evaluation involves the evaluation of goal achievement and review of the evaluation of goal achievement and review of the nursing care plannursing care plan

EVALUATION= EVALUATION OF GOAL EVALUATION= EVALUATION OF GOAL ACHIEVEMENT + REVIEW OF THE CARE ACHIEVEMENT + REVIEW OF THE CARE PLANPLAN

SOPIE FORMAT SOPIE FORMAT CHARTINGCHARTINGSAMPLE: PATIENT WITH KETOACIDOSISSAMPLE: PATIENT WITH KETOACIDOSIS

DATE/ DATE/ TIMETIME

S: Client states ”I feel sick all over.” S: Client states ”I feel sick all over.” Client claims difficulty in breathing, Client claims difficulty in breathing, abdominal pain, and nauseaabdominal pain, and nausea

O: Lung clear, RR 28/min, labored. O: Lung clear, RR 28/min, labored. Abdominal distended, bowel sounds Abdominal distended, bowel sounds underactive all four quadrants, 5+ underactive all four quadrants, 5+ abdominal painabdominal pain

A: Alteration in nutrition and comfort A: Alteration in nutrition and comfort R/T ketoacidosis. Blood sugar R/T ketoacidosis. Blood sugar 460mg/dl. Ketones strongly positive, 460mg/dl. Ketones strongly positive, pH <7.3pH <7.3

DATE/ DATE/ TIMETIME

DATE/ DATE/ TIMETIME

P: Maintain IV infusion of 0.9%NS P: Maintain IV infusion of 0.9%NS with regular insulin as ordered. NPO. with regular insulin as ordered. NPO. Oral hygiene hourly. Maintain Oral hygiene hourly. Maintain accurate I&O. Assess for rales, accurate I&O. Assess for rales, hypotension, cardiac dysrhythmias. hypotension, cardiac dysrhythmias. Monitor blood glucose and Monitor blood glucose and electrolytes. SIGNATUREelectrolytes. SIGNATURE

I: Called Dr. Reyes, blood sugar I: Called Dr. Reyes, blood sugar 460mg/dl, IV bolus regular insulin 460mg/dl, IV bolus regular insulin given as ordered, 1000ml 0.9%NS given as ordered, 1000ml 0.9%NS infusing @ 1L/H central line 1. 50U infusing @ 1L/H central line 1. 50U regular insulin in 500 mL NS infusing regular insulin in 500 mL NS infusing @ 50 mL/H central line 2. EKG taken. @ 50 mL/H central line 2. EKG taken. SIGNATURESIGNATURE

E: Lungs clear, RR 24/min, E: Lungs clear, RR 24/min, nonlabored, 3+ abdominal pain. nonlabored, 3+ abdominal pain. Urinary output 750 ml/hour. Blood Urinary output 750 ml/hour. Blood glucose 360 mg/dl. SINATUREglucose 360 mg/dl. SINATURE

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