Components of Nursing Documentation

Activities include the concept of documentation:

Communication

Effective documentation skills enable nurses to communicate to other health workers and explain what has been, is, and that will be done by nurses

Documentation of nursing process

Recording nursing process is the appropriate method for systematic decision-making, problem solving, and further research. Documentation of nursing process includes assessment, problem identification, planning and action. The nurse then Observing and evaluating the response to the actions of a given client, and communicate information to other health personnel.

Standard documentation

Nurses need something skills to meet documentation standards. Standard documentation is a statement about quality and quantity of documentation that dipertimnbangklan adequately in a given situation. Standard documentation is useful to strengthen the recording pattern and the instructions or guidelines for documenting practices in providing nursing actions.

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Principles of Management of Emergency Disorders

NusingNetwork ,--The main principle of management of emergency nursing care is to maintain the airway and provide adequate ventilation, resuscitate when needed. Assess injury and airway obstruction. In addition, control of bleeding and restoration of cardiac output and prevent and deal with shock, and maintain circulation Obtain a continuous physical examination, serious injury or illness from a non-static patient Determine whether the patient can follow orders, evaluation, size and pupil activity and motor responses. Then, monitor the ECG, if necessary do management if there is a suspected cervical fracture with head injury by protecting the wound with a sterile dressing. Check whether the patient is using medical precautions or the identity of allergies and other health problems. Then check the flow of vital signs, blood pressure and neurologic status to gain clues in making decisions. Evaluation Management of Emergency Disorders After getting adequat...

NANDA Nursing Diagnosis Domain Nutrition

Ingestion. Imbalanced nutrition: less than body requirements (Nursing care Plan). Readiness for enhanced nutrition. Insufficient breast milk production. Ineffective breastfeeding (Nursing care Plan). Interrupted breastfeeding (Nursing care Plan). Readiness for enhanced breastfeeding. Ineffective adolescent eating dynamics. Ineffective child eating dynamics. Ineffective infant feeding dynamics. Ineffective infant feeding pattern (Nursing care Plan). Obesity, Overweight, Risk for overweight, and Impaired swallowing (Nursing care Plan). Risk for unstable blood glucose level (Nursing care Plan).Neonatal hyperbilirubinemia. Risk for neonatal hyperbilirubinemia. Risk for impaired liver function. Risk for metabolic imbalance syndrome.

Family nursing diagnoses

Family nursing diagnosis is formulated based on data obtained in the assessment of nursing problems that will be associated with the etiology stemming from the assessment of the family care function. Nursing diagnosis refers to the PES which can be used for problem formulation NANDA. Typology of family nursing diagnoses consisted of: 1. Actual (deficit) 2. Risks (health threat) 3. Welfare state (wellness) Example family nursing diagnoses: Family Actual Nursing Diagnoses 1. Nutritional deficiencies: lack of demand in toddlers (Child M), Mr R family in touch with the family knowing ignorance nutritional deficiency problem. 2. Nutritional deficiencies: lack of demand in toddlers (Child M), Mr R family in touch with family unwillingness to take decisions / actions to address the problem of nutritional deficiencies. 3. Nutritional deficiencies: lack of demand in toddlers (Child M), Mr R family associated with the inability of families caring for family membe...

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