By Susan A. Newfield, Mittie D. Hinz, Donna Scott-Tilley, Kathryn L. Sridaromont, Patricia Joy Maramba
Read or Download Cox's Clinical Applications of Nursing Diagnosis: Adult, Child, Women's, Psychiatric, Gerontic, and Home Health Considerations 5th Edition PDF
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Additional info for Cox's Clinical Applications of Nursing Diagnosis: Adult, Child, Women's, Psychiatric, Gerontic, and Home Health Considerations 5th Edition
3. The plan of care 4. The progress notes Including the key components and validating the quality of the written nursing actions help promote improved documentation. In essence, the written nursing actions can give an outline for documentation. Properly written nursing actions demonstrate to the nurse both nursing actions and documentation to be done. Referring to the preceding example, we can see that the nurse responsible for this patient’s care should chart the patient’s blood pressure (BP), pulse (P), and respiration (R) rates prior to the activity, the patient’s BP, P, and R rates after the activity, the presence or absence of vertigo, the presence or absence of pain, and the results of a circulatory check.
In the long-term care facilities, such as home health, rehabilitation, and nursing homes, long-range problem solving is possible, but setting priorities of care is still necessary. Several methods of assigning priorities are available. Some nurses assign priorities based on the life threat posed by a problem. For example, Ineffective Airway Clearance would pose more of a threat to life than the diagnosis Risk for Impaired Skin Integrity. Some nurses base their prioritization on Maslow’s Hierarchy of Needs.
Resolved”) and revises the plan to include the new nursing diagnosis with its appropriate expected outcome and nursing actions. Continue indicates that the expected outcome has not been met. The nurse again collects the appropriate data and, based on the data, makes the nursing judgment that the expected outcome has not been met. ” She then modiﬁes the plan of care by going back to the stated expected outcome, marking one line through the date, and adding a new date. Likewise, the nursing actions would be modiﬁed as necessary.
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