documentation is an important part of nursing practice‚ in the clinical setting (Perry & Potter‚ 2014). One of the fundamental aims for nurses in all areas is to safeguard the welfare of their patients through proper documentation ((Nursing and Midwifery Board of Australia - Codes and Guidelines‚ n.d). This can be achieved by implementing and upholding good documentation practice through progress notes writing in every healthcare department specifically nursing (Miller & Cameron‚ 2011). In this briefing
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The health care environment has drastically changed over the years with advanced technology. Several disciplines are adjusting to the changes to meet the demands that a diverse society has embraced. Among the several fields of discipline‚ nursing has greatly evolved especially in terms of educational practice. Traditional methods such as lecture‚ video presentation‚ and reporting may be of less significance with the advent of modern technology. The integration of technology in nursing poses a
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STUDY ..................................... 4 A. DEFINITION B. SIGNS/SYMPTOMS C. CAUSES V. PATIENT’S PROFILE ..................................................... 5 VI. NURSING HISTORY....................................................... 6 A. PRESENT ILLNESS B. PAST ILLNESS C. FAMILY HISTORY D. SOCIO-ECONOMIC VII. GORDON’S ................................................................. 7 VIII. PHYSICAL ASSESSMENT ......................................
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“Nursing Care Plan for Mechanically Ventilated Patient” Alexandra Diaz ITT Technical Institute NU270 NURSING CARE PLAN Assessment: Mechanically ventilated patient requiring sedation as evidenced by patient’s increased agitation. Nursing Diagnosis: Ineffective Airway Clearance r/t presence of artificial airway. Planning/Interventions: • Auscultate lung sounds bilaterally q1 to 4 hours. “Breath
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Nursing Care Plan Assessment | Nursing Diagnosis | Rationale | Objective/s | Nursing Interventions | Rationale | Evaluation | OBJECTIVE:Clinical jaundice evident within 24 hour of birth | Risk for fluid volume deficit related to phototherapy | Phototherapy enhances the excretion of unconjugated bilirubin through the bowel. | The infant will exhibit no signs of dehydration‚ clear amber urine output of 1-3 mL/kg/hr‚ and will display appropriate weight gain. | 6. Initiate early feedings and offer
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Nursing Care Plan Problem: Impaired Ventilation | Assessment |Nursing Diagnosis |Planning |Intervention |Rationale |Evaluation | |Subjective: |Impaired spontaneous ventilation |Within 8hrs of nursing |Independent: | |
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Therapeutic Communication Jane Vuong‚ a 24 year old Vietnamese undergraduate student was admitted into the hospital Emergency Department presenting with anxiety‚ difficulty speaking‚ breathing and dusky lips following severe chest tightness during an exercise session at the local martial arts school. On examination she had a wheezing sound when breathing. She has no history of asthma but says she has some allergies which she treats with herbs. Her colleague who brought her to the emergency room also
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orthopedic patient. The shift started at 1600 on post operation day one. The care plan for Gemma for the PM shift will employ clinical reasoning cycle: including nursing problems in order of priority‚ interventions with rationales and evidences‚ evaluations on Gemma’s performance. This nursing diagnoses and care plan is to focus on early detection and prevention of complications associated with post operation of THR. PART A: Nursing Diagnosis 1. Diagnosis: Breathing problems related to effect of anesthesia
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delivering information‚ knowledge‚ and caring patients. Organizations rely on information systems to carry out and manage their operations‚ interact with their customers (patients) and vendors‚ and compete in the marketplace. * For instance‚ a health care organization like Kaiser Permanente uses information systems to reach their potential customers with targeted messages over the Web‚ to process‚ and to manage their health records. * An example web site kp.org enables patient’s to access their
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Adaptation Model Mary E. Tiedeman Sister Callista Roy received a bachelor’s degree in nursing in 1963 from Mount Saint Mary’s College. She received a master’s degree in pediatric nursing in 1966‚ a master’s degree in sociology in 1975‚ and a doctorate in sociology in 1977‚ all from the University of California‚ Los Angeles. In 1985‚ she completed a 2-year postdoctoral fellowship in neuroscience nursing at the University of California‚ San Francisco‚ and she spent an additional 2 years doing
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