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Discussion

Charting Inquiry

nurse-charting-family-affecting-patient.jpg.a5e38ce04745e303ff61fc7f44a6d1f2.jpg

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.

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    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 ~

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