1.
DEFINITIONS: <ul><li>Focus Charting - is a method for organizing health information in the individual's record. It is a systematic approach to documentation, using nursing terminology to describe individual's health status and nursing action. </li></ul><ul><li>Focus </li></ul><ul><li>a key word or diagnostic category from a nursing diagnosis or collaborative problem on the plan of care (action plan), i.e. skin integrity, coping, activity tolerance, self care deficit </li></ul><ul><li>a current individual concern or behavior, i.e. nausea, chest pain, pre-op teaching, hospital admission </li></ul><ul><li>a sign or symptom of (possible) importance to the nursing and/or medical diagnosis or treatment plan, i.e. fever, constipation, hypertension, incontinence, lethargy </li></ul><ul><li>an acute change in an individual's condition, i.e. respiratory distress, seizure, fever, discomfort </li></ul><ul><li>a significant event in an individual's care, i.e. begin treatment regimen (oxygen), change in diet, catheterization </li></ul><ul><li>a key word or phrase indicating compliance with a standard of care or agency policy, i.e. self medication teaching plan, transition </li></ul>

2.
COMPONENTS OF A FOCUS NOTE: <ul><li>Data: Subjective and/or objective information supporting the stated focus or describing observations at the time of significant events. </li></ul><ul><li>Action: Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated. </li></ul><ul><li>Response: Description of individual's response to medical and/or nursing care. Statement that the Action Plan of Care outcomes have been attained or are progressing toward attainment. </li></ul>

3.
<ul><li>Example: </li></ul><ul><li>Need: Comfort (or, Relief of pain ) D - Complaining of continuous, sharp pain in mid-abdominal incisional area. Crying. &quot;I need something for pain now!&quot; States pain is 9 on a scale of 10. A - Medicated with Demerol 75mg IM in LUOQ of left buttock. Repositioned on right side with pillow to abdomen to help splint wound. R - Patient stated pain was &quot;much better&quot; 30 minutes later and rated it 3 on a scale of 10.---N. Nurse </li></ul>

4.
General Survey <ul><li>Appearance of the patient, condition- when seeing the patient </li></ul><ul><li>Any IVF or Medications attaches to the arms of the patient </li></ul><ul><li>Current Vital Signs of the Patient </li></ul><ul><li>Eg. </li></ul><ul><li>Approached sitting on bed, awake, responsive, coherent with ease in respiration, with O2 at 2 LPM, with an IVF of 4 PLR 1L + 8.25 meq KCl @ 66 ugtts/min infusing well at the Right arm, with the following V/S: BP= 110/70 mmHG, PR= 100 bpm, RR= 26 cpm, T= 36.8 degree Celsius/axilla. </li></ul><ul><li>Followed by F-DAR </li></ul><ul><li>After writing the F-DAR , at the end of the shift write again your general observation/survey of the patient condition </li></ul>

5.
<ul><li>F: Hyperthermia </li></ul><ul><li>D: > increase in body temperature above normal range to T= 38 degree Celsius/axilla </li></ul><ul><li>> flushed skin and warm to touched </li></ul><ul><li>A: 9:00am </li></ul><ul><li>> Tepid sponge bath done </li></ul><ul><li>> instructed SO to let patient wear loose clothing </li></ul><ul><li>> instructed SO to provide blanket to patient when shiver </li></ul><ul><li>> instructed SO to let patient drink lots of fluid </li></ul><ul><li>> instructed SO to include in his diet foods rich in Vitamin C such as oranges </li></ul><ul><li>> provided opportunity for patient to rest </li></ul><ul><li>> due meds given </li></ul><ul><li>R: 1:00pm </li></ul><ul><li>> patient was able to rest </li></ul><ul><li>> patient temperature decrease to T= 37.8 degree Celsius/axilla </li></ul>

6.
<ul><li>F1: Ineffective Breathing Pattern </li></ul><ul><li>D1: increase respiratory rate of 24 cpm </li></ul><ul><li>D2: use of accessory muscle to breath </li></ul><ul><li>D3: presence of nonproductive cough </li></ul><ul><li>F2: Hyperthermia </li></ul><ul><li>D1: skin warm and flush to touched </li></ul><ul><li>D2: increased body temperature of T= 37.7 degree celsius/axilla </li></ul><ul><li>F3: Fatigue </li></ul><ul><li>D1: less movement noted with the verbalization of “kapoy man ako lawas, kulangan ko ug katulog” </li></ul><ul><li>A: 9:00am </li></ul><ul><li>monitored v/s and charted </li></ul><ul><li>regulated IVF and charted </li></ul><ul><li>morning care done </li></ul><ul><li>assessed patient needs and performed handwashing before handling the patient </li></ul><ul><li>advised SO to always stay on patient bedside </li></ul><ul><li>promote proper ventilation and a therapeutic environment </li></ul>

7.
<ul><li>elevated the head of the bed (moderate high back rest) </li></ul><ul><li>provided comfort measures and provide opportunity for patient to rest </li></ul><ul><li>due meds given </li></ul><ul><li>9:30am </li></ul><ul><li>tepid sponge bath done </li></ul><ul><li>instructed SO to provide blanket and let patient wear loose clothing </li></ul><ul><li>F4: Discharge Plan (12:00nn) </li></ul><ul><li>D1: discharged order given by Dr.Name/Time </li></ul><ul><li>M – advised SO to give the ff. meds at the right time, dose, frequency and route </li></ul><ul><li>E – encouraged to maintain cleanliness of the house and surroundings </li></ul><ul><li>T – advised to go to follow-up consultations on the prescribed date </li></ul><ul><li>H – encouraged to do chest tapping to facilitate mobilization of secretion </li></ul><ul><li>O - observed for signs of super infections such as fever, black fury tongue and foul odor discharges </li></ul><ul><li>D – encouraged to eat fresh vegetables and fish </li></ul><ul><li>S – advised to continue praying to God and hear mass on Sunday </li></ul><ul><li>2:00pm – out of the room per wheelchair with improved condition </li></ul>

8.
<ul><li>Discharge plan for patient who undergo Surgery </li></ul><ul><li>H – Health Teachings </li></ul><ul><li>A – Anticipatory Guidance </li></ul><ul><li>S - Spirituality </li></ul><ul><li>M - Medications </li></ul><ul><li>I – Incision in Care </li></ul><ul><li>N - Nutrition </li></ul><ul><li>E - Environment </li></ul>