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NURSING KARDEX
RECORDING
Mrs. . V.Swarajya lakshmi
Principal
GCON,MBNR.
NURSING KARDEX
• Nurses use kardex to communicate
important information about their
patients.
• Explore this nurses resource with a
description of its definition and uses in
nursing
PURPOSE OF NURSING KARDEX
•To serve as a record of medical and nursing
orders
•Each patient in the ward cared for by the
students of the college of nursing.
MAINTENANCE OF NURSING KARDEX:
•A Kardex from will be maintained for all
patients cared for by the college of nursing
students.
•It will be filled out when a patient is first
assigned to a student.
•It will be checked and revised as needed, before
giving care and daily after doctors rounds.
Red ink will be used to indicate the time of
administration of medications from 7 p.m. to 7
a.m.
Drawing a red line through the order and
writing the date and the initials of person
canceling the order above the line will do
cancellation of the orders.
b) Black ink will be used to indicate the time
of administration of orders 7 a.m. to 7 p.m.
•Only standard abbreviations will be used in
writing orders on the Kardex.
•Do not abbreviate the name of the medications.
•The medication order should not be rubbed or
over written.
a) Ink will be used for all the following recordings.
• Name
• Age
• IP No
• Religion
• Doctor’s name
• Medication
Date
Dose
Time
b) Pencil is used for the following recording
• Bed no.
• Diagnosis
• Bath type
• T.P.R & B.P. frequency and method
• Diet
• Nursing care plan
Date
Time
• Specific Treatments
Method of filling Kardex
I. Identification Data:
- Use capital letters to record.
- Name – copy accurately and completely from
the admission record
- Diagnosis – Record provisional diagnosis.
- Any change in the working diagnosis.
- Surgical procedure done with date.
II. Medication:
a) Write date, form and the name of the
medication, frequency of administration in 24
hours, route of administration if other than oral
and specific instructions concerning
administration in column marked “medication”.
b) In column marked “Dosage” Write the
amount to be administered at the time of each
administration.
c) In the column marked “time” write the hours
of administration.
d) Stat, P.R.N. and S.O.S. medication orders
should not be recorded in the Kardex card but
the medicine card should be prepared and should
be inserted in the Kardex.
e)Alternate day, weekly and bi weekly
medications with the pencil the due dates for
three consecutive dosages
III. Treatments:
a) In the column marked “treatment” write the
date and name of the treatment, Example I/V,
irrigation, diet, therapy,
external applications, baking, frequency in 24
hours.
And if applicable site, duration, temperature or
strength of solutions and any special
instructions.
IV. Nursing Care Plan
a) Write order relating to needed nursing care
plan of the patient such as
Hygienic care:
- Special Mouth care
- Shampoo
- Posture and position –
Frequency in 24Hrs
- Activity, rest and exercise.
- Control of pain
- Needs for health teaching or nursing care
following discharge.
- Needs for support in relation to emotions or
mental attitudes.
- Food or Fluid – Intake
- Type
- Amount
- Frequency
- Elimination
- Use of comfort devices and safety measures.
Recreation and diversion.
- Plan to meet the spiritual needs
- In the “time” column indicate the specific
hours for carrying out nursing care if applicable.
- Bath – Record if bed bath or shower,
frequency and if not daily the specific days of
week the bath is to be given.
- - T.P.R. – Record the method of taking if other
than oral.
- Diet – Record the type of diet ordered,
supplementary feedings, if ordered.
Limitation of food or fluid if applicable.
- Health education of;
- Disease
- General
- Family Planning
- Prevention of disease etc.,
References
1. Kozier
NURSING KARDEX RECORDINGppt.pptx

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NURSING KARDEX RECORDINGppt.pptx

  • 1. NURSING KARDEX RECORDING Mrs. . V.Swarajya lakshmi Principal GCON,MBNR.
  • 2. NURSING KARDEX • Nurses use kardex to communicate important information about their patients. • Explore this nurses resource with a description of its definition and uses in nursing
  • 3. PURPOSE OF NURSING KARDEX •To serve as a record of medical and nursing orders •Each patient in the ward cared for by the students of the college of nursing.
  • 4. MAINTENANCE OF NURSING KARDEX: •A Kardex from will be maintained for all patients cared for by the college of nursing students. •It will be filled out when a patient is first assigned to a student. •It will be checked and revised as needed, before giving care and daily after doctors rounds.
  • 5. Red ink will be used to indicate the time of administration of medications from 7 p.m. to 7 a.m. Drawing a red line through the order and writing the date and the initials of person canceling the order above the line will do cancellation of the orders.
  • 6. b) Black ink will be used to indicate the time of administration of orders 7 a.m. to 7 p.m. •Only standard abbreviations will be used in writing orders on the Kardex. •Do not abbreviate the name of the medications. •The medication order should not be rubbed or over written.
  • 7. a) Ink will be used for all the following recordings. • Name • Age • IP No • Religion • Doctor’s name • Medication Date Dose Time
  • 8. b) Pencil is used for the following recording • Bed no. • Diagnosis • Bath type • T.P.R & B.P. frequency and method • Diet • Nursing care plan Date Time • Specific Treatments
  • 9. Method of filling Kardex I. Identification Data: - Use capital letters to record. - Name – copy accurately and completely from the admission record - Diagnosis – Record provisional diagnosis. - Any change in the working diagnosis. - Surgical procedure done with date.
  • 10. II. Medication: a) Write date, form and the name of the medication, frequency of administration in 24 hours, route of administration if other than oral and specific instructions concerning administration in column marked “medication”. b) In column marked “Dosage” Write the amount to be administered at the time of each administration.
  • 11. c) In the column marked “time” write the hours of administration. d) Stat, P.R.N. and S.O.S. medication orders should not be recorded in the Kardex card but the medicine card should be prepared and should be inserted in the Kardex. e)Alternate day, weekly and bi weekly medications with the pencil the due dates for three consecutive dosages
  • 12. III. Treatments: a) In the column marked “treatment” write the date and name of the treatment, Example I/V, irrigation, diet, therapy, external applications, baking, frequency in 24 hours. And if applicable site, duration, temperature or strength of solutions and any special instructions.
  • 13. IV. Nursing Care Plan a) Write order relating to needed nursing care plan of the patient such as Hygienic care: - Special Mouth care - Shampoo - Posture and position – Frequency in 24Hrs - Activity, rest and exercise. - Control of pain
  • 14. - Needs for health teaching or nursing care following discharge. - Needs for support in relation to emotions or mental attitudes. - Food or Fluid – Intake - Type - Amount - Frequency - Elimination - Use of comfort devices and safety measures.
  • 15. Recreation and diversion. - Plan to meet the spiritual needs - In the “time” column indicate the specific hours for carrying out nursing care if applicable. - Bath – Record if bed bath or shower, frequency and if not daily the specific days of week the bath is to be given.
  • 16. - - T.P.R. – Record the method of taking if other than oral. - Diet – Record the type of diet ordered, supplementary feedings, if ordered. Limitation of food or fluid if applicable. - Health education of; - Disease - General - Family Planning - Prevention of disease etc.,