Charting Inquiry

[ladysyrah]

Working as a private duty nurse, you spend extended times with your patient and their family. How would you consider charting if family issues are directly affecting the patient (ie causing -extra- stress, anxiety, depression due to fights occurring in patient’s presence)? I appreciate all thoughts! I believe it is very negatively affecting my patient and I’ve verbalized as much (respectfully of course) but don’t know how or if I should go about it in my documentation.

[JKL33]

Tough situation.

No specific recommendations but you could consider carefully choosing an appropriate nursing diagnosis (yes, I just said that ??) and documenting your assessments and interventions being careful to be objective and use professional terms and phrasing. This is as good a situation as any to use the actual nursing process. Make your dx, choose interventions, implement them, reassess.

Hopefully others will have some ideas for you.

Good luck ~