CareScribble. User Guide. Ver Stofukerfi ehf Copyright Sto fukerfi ehf

Transcription

1 CareScribble Ver. 5.5 User Guide 2013 Stofukerfi ehf Copyright Sto fukerfi ehf 1

2 Contents CareScribble... 3 Introduction... 3 Registration... 4 Support and Updates... 4 Main Window... 5 Menus... 5 Designer Overview... 6 How to View a Definition... 8 How to View a Diagnosis... 9 How to View an Intervention CareScribble Designer How to Add a Care Plan in Designer How to Add a Diagnosis in Care Plan How to Add a Related Factor (Symptom and Outcome) in a Care Plan How to Add an Intervention in a Care Plan How to View or Print a Care Plan

3 Introduction CareScribble Thank you for your interest in CareScribble, a useful utility used to create and edit nursing care plans. Loaded with features, CareScribble makes it easy to create, maintain, modify, view, and print nursing care plans. The most notable features are outlined below: Creating and Maintaining Nursing Care Plans Use CareScribble to enter and update: Nursing diagnoses Nursing interventions Nursing tasks (related to interventions) Symptoms (related to nursing diagnoses) Related factors (related to nursing diagnoses) Outcomes (related to nursing diagnoses) Preview, Print, and/or Export Nursing Care Plans After creating a care plan, you can easily: Print whole or partial nursing care plans Export nursing care plans to PDF and Microsoft Word Note: CareScribble is not intended for storing any patient's sensitive data such as name, address, phone number, or other personal information. System Requirements: Microsoft Windows XP and above 3

4 Registration CareScribble is free to try. When the free demo version expires, we're confident that you'll find the time-savings and ease of use well worth upgrading to the standard version of CareScribble. To register your demo version of CareScribble: 1. Click on the 'Buy' button on the 'Demo has Expired' screen below: Note: If you have already purchased the full version of CareScribble, then proceed to step Check your for the message containing your registration code. 3. Enter your registration information exactly as it appears in the confirmation Click the 'OK' button Support and Updates We are committed to developing quality nursing care plan solutions and respond promptly to inquiries. Send your questions to: Updates As a registered user, you will receive periodic CareScribble updates for free. To check for updates in CareScribble: Select Main Menu ---> Help Check for updates Click on "Check for updates" If an update is available, it will install automatically 4

5 Menus Main Window The Menubar CareScribble was developed with ease of use in mind. Along the top, you'll notice just a few standard menus: Files --> Print Setup --> Designer --> View Diagnosis--> View Interventions--> Quit Help --> Contents --> Index --> How to use help --> CareScribble Web --> Check for updates --> Register product --> About Windows --> Tile --> Cascade --> Arrange Icons Shortcut Buttons CareScribble includes three shortcut buttons that quickly take you to the core areas of the software: Designer This shortcut takes you to 'Designer' where you design your nursing care plans. Diagnosis and linked components This shortcut takes you to the list containing diagnoses and linked components (such as related factors, symptoms, and goals). Use this list to 'lookup' information in Designer when composing nursing care plans. Note: Each new record entered in a care plan is stored in this lookup list for future use when composing new care plans. You can edit the list in this section as well. Interventions and linked actions This shortcut takes you to the list containing interventions and linked nursing tasks. This list is used for 'lookup' in Designer when composing nursing care plans. Note: Each new record entered in a care plan is stored in this lookup list for future use when composing new care plans. You can edit the list in this section as well. 5

6 Designer Overview Designer is the part of the CareScribble utility where nursing care plans are designed and maintained. On the left screen, you'll see a list of named care plans. On the right, you'll see the records associated with each care plan you select. When you select a different care plan, the right side of the screen will change to display the records for the selected care plan. It is very important that you understand how the records in care plans are connected. To better understand this, review the schematic description below: 6

7 In other words: For each Care Plan, there can be one or more Nursing Diagnoses. For each Nursing Diagnosis, there can be one or more Related Factors, Symptoms/Risk factors, Outcomes/Goals, and Interventions. For each Intervention, there can be one or more Tasks. The Number, Size, and Content of Nursing Care Plans in CareScribble are Unlimited. The size and content of your care plans can be adjusted using the 'Tag' and 'Untag' feature. For example, if you have a stored care plan containing about 10 diagnoses and only four of those diagnoses and underlying data apply to your selected patient, then you would tag only those four diagnoses and underlying data. When viewing or printing your modified care plan, only those tagged items wiould appear. This is the strength of CareScribble: The size and content of a care plan can be adjusted as needed as it relates to each patient's health status. Overview of Designer Functions 7

8 How to View a Definition Use the Designer section to view definitions of each nursing diagnosis and intervention of any care plan. 8

9 How to View a Diagnosis This list above contains available Nursing Diagnosis, Related factors, Symptoms, Outcomes, Interventions, and Tasks stored in a special database used for 'lookup' in Designer when composing care plans. You can also edit records in this section. Note: Each new record entered in a care plan (or here) is stored for future use when composing care plans. 9

10 How to View an Intervention This list above contains Interventions and Tasks stored in special database which is used for 'lookup' when composing care plans in Designer. Records can also be edited here. Note: Each new record entered in a care plan (or here) is stored for future use when composing care plans. 10

11 CareScribble Designer How to Add a Care Plan in Designer Note: The maximum number of characters in a Care Plan name is

12 How to Add a Diagnosis in Care Plan Note: The maximum number of characters allowed in a diagnosis name is

13 How to Add a Related Factor (Symptom and Outcome) in a Care Plan Note: The maximum number of charactors for a related factor, symptom, or outcome name is

14 How to Add an Intervention in a Care Plan Note: The maximum number of characters in an intervention name is 50 and in a task name is

15 How to View and Print a Care Plan To view or print a selected nursing care plan, click on the 'View/Print' button in Designer. The selected (and tagged) care plan is displayed in Report Previewer mode and can be printed and/or exported as PDF document and MS WORD document. Print all Print page Exit Export to PDF Export to WORD TIP: If the layout (and content) of a previewed care plan needs to be changed or modified, save (export) it as Word documnet. From there, you can change or modify the care plan before printing. 15

16 Example of Printout / PDF/ MS Word Care Plan: AdemoPostOp Nursing Diagnosis Nr. Date Intervention/s and tasks Sign. Pain Management Asses cause of pain Instruct patient to relax and rest Administer O2 as orderd Analgesic Administration Administer medication as prescribet Obs. pain (effectivnes of medication) Acute pain Related factors: Result form surgery Symptoms/Risk factors: Facial mask Verbal or coded report Expressive behavior (e.g., restlessness, moaning, Outcome/Goal: Patient appears relaxed and comfortable Patient verbalizes relief of pain Impaired skin integrity Related factors: surgical procedure Physical immobilization Symptoms/Risk factors: surgcial wound bleeding Destruction of skin layers (dermis) Temp > 38.5 Outcome/Goal: surgcial wound clean Risk for imbalanced fluid volume Related factors: Fluid loss or bleeding Symptoms/Risk factors: increased pulse rate tachycardia low blodpressure Outcome/Goal: Vital sign normal ( as before surgical procedure) Fear Related factors: Unfamiliarity with environmental experience(s) Symptoms/Risk factors: Increased alertness Increased respiratory rate and shortness of breath Fatigue Outcome/Goal: Demonstrates reduced leves of anxiety Nausea Related factors: anesthesia surgical procedure Symptoms/Risk factors: Report of nausea (sick to stomach) Outcome/Goal: Patient verbalizes relief of Nausea Activity intolerance Related factors: Fear and pain Side effects of medication Symptoms/Risk factors: Verbal report of fatigue or weakness Outcome/Goal: Patient maintains activity level within capabilites Incision Site Care Obs dressing (bleeding) Change dressing as prescribet Obs. signs of infection Fluid Monitoring Obs vital signs Bp. O2 and pulse obs urine output Obs fluid balance hour Fluid Management Maintain intravenous infusion as prescribed Encourage patient (if prescribet) to take in po fluid Anxiety reduction Assess reasons for anxiety Inform patient about his stay in the post op care unit Explain all procedure as appropriate Reduce unnecessary externa stimuli Presence Active Listening Nausea Management Administer O2 Administer antiemetic drugs as prescribet Restrict oral intake until nausa / vomiting stops Teaching: Prescribed Activity/Exercise Encourage activity as tolerated, rest as needed Obs. symptoms(comfort,vital sign and skin color) of patients activity Discharge Planning Ascertain that patient has follow-up care arranged at discharge Teach the patient / caregiver about wound care using aseptic technique Plan created: by: Signature 16