Nursing knowledge: Charting sufferer Care deals how-to assistance at the most modern concepts and tendencies in documentation, equipping nurses with the "know-how" to successfully and competently rfile sufferer care admission to discharge. The e-book is written in paragraph and bulleted layout, with countless numbers of pattern filled-in kinds and narrative notes that exhibit the easiest and most secure charting techniques.
Know-How icons provide professional suggestion on find out how to record. Case Clip icons current scientific situations related to particular events, and establish the position fast reaction workforce performs in responding to the location. Legal Lookout icons current criminal suggestion approximately documentation and real-world complaints the place cautious nursing documentation is especially vital.
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Nursing information: Charting sufferer Care deals how-to advice at the most up-to-date suggestions and developments in documentation, equipping nurses with the "know-how" to successfully and properly rfile sufferer care admission to discharge. The publication is written in paragraph and bulleted layout, with 1000s of pattern filled-in kinds and narrative notes that display the easiest and most secure charting thoughts.
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Extra info for Nursing Know-How: Charting Patient Care
Monitor and document heart rate and rhythm, heart sounds, and BP. Note the presence or absence of peripheral pulses. qxd 8/21/08 50 7:34 PM Page 50 Documenting from admission to discharge Using a standardized care plan The standardized care plan below is for a patient with a nursing diagnosis of Impaired tissue integrity. To customize it to your patient, complete the diagnosis— including signs and symptoms—and fill in the expected outcomes. Also modify, add, or delete interventions as necessary.
Yes Alert physician and anticipate changes in drug therapy. Documenting the patient-teaching plan Several forms are available for documenting patient-teaching plans, including some that detail the phases of the nursing process as they relate to patient education. qxd 8/21/08 7:34 PM Page 53 Nursing diagnoses and care plans 53 KEY Assessment Nursing diagnoses Interventions Evaluation Impaired gas exchange related to fluid accumulation in lungs Limit fluid and sodium intake as ordered. Administer oxygen (O2) therapy.
Types of nursing diagnoses Depending on the policy of your health care facility, you’ll either use standardized diagnoses or formulate your own diagnoses. Benefits of using standardized diagnoses Ⅲ By using nationally standardized diagnoses, such as NANDA-I Taxonomy II, health care facilities make communication easier and diagnoses more precise. Ⅲ Diagnoses can be categorized according to nursing models, but other ways of categorizing diagnoses—for instance, according to Orem’s selfcare model—may also be used.
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