Lindar

Well we are told on our unit to use what is called BIRP charting. B is behavoir. Chart what you see, their mood and affect and what are they doing. I is for Intervention-What did you do for this person meaning what is your nursing intervention. These interventions usually come from something we call a Treatment plan. They could be called care plans. R-response. How did the patient respond to the nursing intervention. They may or may not respond. Maybe you tried to distract or redirect and it was effective or ineffective. P-plan. What do you plan to do from here. This would be your goals. They too are usually in the Treatment Plan. It would look something like this. B-Patient presented sitting in geri chair in day room, alert but oriented to person only. Grossly confused and combative. Fidgeting in chair and many attempts to ambulate. Patient uses walker to ambulate but gait is unsteady. Skin tear noted to left hand with steri strip intact. Patient is also hard of hearing. I-Attempted medication administration. Listened and attempted verbal redirection. Spoke in short concise concrete statements to accomodate hearing loss. R-Patient threw pills on the floor and stated, "I am not taking those unless God tells me to." P-Discuss with Physician possible secondary route for medication. Continue to monitor causes of patients agitation. Remove patient from stimulating situation. Continue to offer comfort and reassurance as needed. I am probably not the best charter around but you get the idea. We actually chart the letters BIRP as I did above.