Model of Nursing Documentation

Source Oriented Record (SOR)

Everyone is a traditional Notes / sections / resource has its own record or separately. Consisting of five components:

1. Admission sheet
2. Doctor's instruction sheet
3. Medical history sheet
4. Note nurses
5. Notes and special reports
6. Graphics card / records

Problem Oriented Record (POR)

Is an effective tool to assist health care teams (Introduced by Dr. Lawrence Weed, USA). Identify patient problems, plan therapy, diagnosis and counseling and evaluating and reviewing progress.

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Definition of a Nursing Diagnosis

NursingNetwork , - A nursing diagnosis is defined by NANDA International (2013) as a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community. New NANDA Nursing Diagnoses In this edition of NANDA nursing diagnosis list (2018-2020), seventeen new nursing diagnoses were approved and introduced. These new approved nursing diagnoses are: Readiness for enhanced health literacy Ineffective adolescent eating dynamics Ineffective child eating dynamics Ineffective infant eating dynamics Risk for metabolic imbalance syndrome Imbalanced energy field Risk for unstable blood pressure Risk for complicated immigration transition Neonatal abstinence syndrome Acute substance withdrawal syndrome Risk for acute substance withdrawal syndrome Risk for surgical site infection Risk for dry mouth Risk for venous thromboembolism Risk for female genital mutilation Risk for occupati...

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.

Nursing

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