Documentation of the nursing care plan is important in order for the patient to receive proper care. All health team members can refer to the record to carry out the necessary steps within the plan (Module 6: Nursing Care Plan, 2012). A nursing care plan is defined by the nursing process. This process involves a scientific approach to problem-solving concerning patient care. The nursing process is individualized to each patient.
This article main purpose is to provide evidence of the importance and application of standardized terminologies in the Nursing practice. A patient care scenario will be used to identify how NANDA, NOC, and NIC elements are applicable. Data, information, knowledge, and wisdom (DIKW) framework will be used to create the patient care scenario. Standardized Nursing terminologies are used by most of healthcare settings as part of Electronic Health Records, and represent nursing data, information, and knowledge that can be stored in the electronic systems to be used as a reference by health care professionals. Scenario A female is referred to home health services for skilled nursing evaluation, and observation.
Week 5 DQ1 The elements that should be included in a comprehensive health assessment for a geriatric patient are the clients past medical history, family history, comorbid conditions and severity as well as current problem list. Current medications should be reviewed in detail, as well as a head to toe physical of all systems. (Ward & Rubin, 2013) The physical exam is an excellent opportunity to check the aging clients hearing and vision. It is also an opportunity to do a cognitive assessment, and assess for bruises or injuries that could indicate an unsteady gait or elder abuse. The clients weight and appearance are an indicator of nutritional status, loose fitting clothing could indicate recent or sudden weight loss, eating habits and dental issues should be assessed, as well as who is preparing the meals.
Health assessment is the orderly collection of information concerning the patient’s and client health status and also is the first step of nursing process. The overall purpose of health assessment is to identify variations from the normal state. The information will become a part of patient database. The health assessment database consists of the both subjective and objective information which alerts nurse to areas to be focused on during examination and support the subjective information given by client during the interview. Health assessment is an evaluation of the health status of an individual by performing a physical examination after obtaining a health history.
Assessment Report for Mr. Brown LaMont Barre Duncain College Assessment Report for Mr. Brown Good morning Mr. Brown. My name is LaMont. I am a physician’s assistant and I will be discussing the results of your recent cholesterol panel. During this appointment we will be reviewing the significance of your results as it directly relates to your heart as well as, formulating a plan of care to help you maintain a healthy lifestyle. Before we begin, are there any specific questions that you have about cholesterol and how it can affect your health?
Proper documentation within state and facility guidelines. Preceptor of new RN’s, as well as providing proper pt education. BRANFORDS HILLS HEALTHCARE CENTER-REHAB UNIT NURSE MAY 2011-PRESENT Responsibilities include admissions, discharges, care plans. Completed assessment of all organ systems. IV’s recognizing issues that arise with pt’s before crisis.
Summary In summary, this research found that there was some benefit of using Vitamin C for improving hemoglobins in patients with ESRD receiving hemodialysis. It also showed that using vitamin C decreased the amount of epogen needed in dialysis patients. This topic would benefit in longer clinical trials with larger groups of participants to study more accurately the effects Vitamin C use has in relation to hyperoxalemia in dialysis
A guide to taking a patient’s history A.Romero Chamberlain College of Nursing NR 305 Health Assessments March 15, 2014 Introduction The article, “ A guide to taking a patient’s history,” which was written by Hillary Lloyd and Stephen Craig (2007) was published in the Art & Science Journal Volume 22, issue number 13 in December issue 2007 presented a remarkable tool to use as a systemic approach for completing a thorough history taking to any patient in perspective. It is an invaluable component providing a nurse or clinician the necessary information to deliver patient care. The article provided issues such as preparation of the environment as the first part of any history taking process, effective communication, allowing sufficient time and organization are also discussed as useful elements for a complete history of a patient. Summary Taking a history of a patient is the most crucial approach of any interventions by nurses or clinicians. It is the most essential elements of information to guide the clinician the necessary care for the patient.
The nurse must execute this process through selection, performance, management and evaluation of nursing actions. The nurse is responsible for assessing the health status of the patients. The RN is a provider for health counseling and teaching patients. The nurse is responsible for administering medications, treatments, and other health regimens that are ordered by a licensed provider. With the practice of the scope of RN, there are also standards that every RN needs to follow.
Based on the clinical diagnosis and patient’s condition, components of the nutrition assessment, diagnoses, and application of evidence-based recommendations for nutritional interventions were made. Disease Description Disease processes that can produce esophageal