This reference provides a guide to effective documentation for nurses in varied settings, and students in clinical rotation. Organized alphabetically, it aims to assist nurses to quickly identify interventions, data, and outcomes appropriate for a specific patient, and document care in as short a time as possible. Specific suggestions are provided for caring for patients with 38 common disorders. The text lists and describes services usually provided by other health professionals, in order to promote appropriate referrals ...
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This reference provides a guide to effective documentation for nurses in varied settings, and students in clinical rotation. Organized alphabetically, it aims to assist nurses to quickly identify interventions, data, and outcomes appropriate for a specific patient, and document care in as short a time as possible. Specific suggestions are provided for caring for patients with 38 common disorders. The text lists and describes services usually provided by other health professionals, in order to promote appropriate referrals and continuity of care. Also included is the Joint Commission on Accreditation of Healthcare Organizations' Standards Related to Documentation, and the American Nurses' Association's Standards of Care. This edition includes nine additional patient problems: intestinal (bowel) obstruction, chemotherapy, dialysis, diarrhoea, eternal care, gastrostomy tube, accute myocardial infarction, pain management, and tuberculosis.
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