dementia charting

[litbitblack, ASN, RN]

Since i have moved to long term care I notice i have been struggling with how i word my charting. I am used to acute care but want more ideas on what and how to chart or maybe wording. Are there any nursing books any one knows of that has charting examples for dementia patients

[shiccy]

If you gave examples of what you're having troubles with, it may help us with giving an answer?

[deleern]

This should be moved to the geriatrics, you will get a better response.

[Ruby Vee, BSN]

i keep mine factual. "patient seems a little off" might fly for report, but for the charting i'd say something more like "attempting to converse with iv pump and using urinal to "water the tulips" that are "growing next to the bed."

[Orca, ADN, ASN, RN]

You can make general statements (i. e., "Seems especially disoriented this morning"), followed by an example of the behavior or statements that make you think that (such as the example Ruby Vee gave above). I stay away from value judgments. As they used to say on Dragnet (for those old enough to remember that show), "Just the facts, ma'am."

[southernbeegirl, BSN, RN]

when charting about dementia in LTC be sure to be specific. it's not good enough to say "pt agitated" or "anxious". be specific, especially if they are on an anitpsychotic med or benzo because those behaviors have to be charted.

i find it easier to chart a specific behavior than a general "anxious". that way yo ucan just say what they are doing and let the reader decide what they think.

example:

sitting up in w/c, propelling self about facility using feet for locomotion. repeatedly asking staff and visitors "where is my momma?" and "how do i go home?". crying at times. unable to redirect behavior. attempts to involve in other activities, folding towels, unsuccessful. continues to ask same questions.