This document discusses different methods of nursing documentation. It describes narrative documentation, problem-oriented medical records (POMR), SOAP/IER notes, PIE notes, and focus charting. It also defines different types of nursing diagnoses like actual, risk, and potential complications. Nursing documentation is an important part of ensuring high-quality patient care. Proper documentation includes recording assessments, care provided, and evaluation of outcomes.
CODE OF ETHICS: The guiding principle in nursing
code are the direction of conduct , understanding of what is right and wrong while providing care in the hospital and community settings.The ICN code of ethics are the milestone to establish nursing as a profession.
CODE OF ETHICS: The guiding principle in nursing
code are the direction of conduct , understanding of what is right and wrong while providing care in the hospital and community settings.The ICN code of ethics are the milestone to establish nursing as a profession.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
gud evening guys
this is descrive you that this ppt is making very simple way and i hope this will help you to understand lightky about nursing theories
For those of you who want to get a head start on the chartsmart, these are the applicable slides. Also, Brenda has a sheet of "Descriptive Terms" that you will want for that project. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
gud evening guys
this is descrive you that this ppt is making very simple way and i hope this will help you to understand lightky about nursing theories
For those of you who want to get a head start on the chartsmart, these are the applicable slides. Also, Brenda has a sheet of "Descriptive Terms" that you will want for that project. She handed it out to a few people the other day who wanted to get a head start on the charting assignment.
In Pharma and Biotech, Weightage of the Documentation is around 70 % because as per FDA "If you do not have Document, You dint have do it."
So Good Documentation Practice is of tremendous importance for the Industry to comply any regulation like FDA, GMP or ISO.
nursing records and reports, definition, purposes, principles, values and uses, types, records in hospital, types of reports, how to write better report, nursing responsibilities
A basic introduction to POMR's Problem oriented medical records.
This is one approach to collect as much data as possible from a patient in order to provide accurate care to a patient. Initally proposed by Dr Lawrence (Larry) Weed this now has become one of the ways information has been collected
Nursing Audit Dr. Rangappa. S .Ashi SDM Institute of Nursing sciences Shri D...rangappa
Nursing audit one of the control tools, responsible for controlling the activities of the nurses that focuses on providing the best possible nursing care. The actual nursing rendered is compared with the standards. This is mainly refers to clinical nursing audit. The nursing management audit is an evaluation of nursing management as a whole. It is critically examination of the entire nursing management process.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Outline :-
• Introduction
• Method of documentation
a. Narrative documentation
b. Problem-Orientated Medical Record (POMR)
c. SOAP/IER
D . The PIE notes
e. Focus Charting
• Nursing diagnosis
• Reference .
3. Introduction :-
Documentation is not separate from care and it is
not optional. It is an integral part of registered
nurse practice, and an important tool that RNs
use to ensure high-quality client care.
The term “documentation” refers to:
any written or electronically generated information
about a client that describes client status or the
care or services provided to that client.
4. Method of documentation :-
Narrative documentation :-
is the traditional method for recording nursing
care provided. It is a story-like format to
document information specific to client
conditions and nursing care.
Data are recorded in the progress notes without
an organizing framework. It often requires the
reader to sort through information to locate
the data required .
5. Guidelines :-
1. the initial entry and assessment, narrative notes include
all patient care activities such as diet, hygiene,
ambulation, elimination, visits from health care
professionals (Dr, dilatation, social worker , etc) or family,
tests, specific problems
2. All entry are signed and dated. Every timed entry must
have a legal signature: 1st initial, last name and legal
status.
3. The last entry on a page must have a legal signature. Plan
the last entry on a page so it has a logical statement and
signature.
4. Each page of narrative notes is a legal document must be
dated–and signed.
6. POMR
Problem-Orientated Medical Record (POMR)
Recording data abut the health status of a
patient I a problem solving system the POMR
preserves the data in an easily accessible way
that encourage ongoing assessment and
revision of the health care plan by all
members of health care team .
All data base is collected before beginning of
identifiying the patient problem .
7. General concepts
• gives emphasis to client’s perceptions of their
problems
• requires continuous evaluation and revision of
the care plan
• provides greater continuity of care among health-
care team members
• enhances effective communication among
health-care team members
• increases efficiency in gathering data
8. SOAP/IER :-
SOAP/IER
One of the most prominent features of this problem-
orientated method of documentation is the structured way
in which narrative progress notes are written by all health-
care team members, using the SOAP, SOAPIE or SOAPIER
format
Subjective the client’s observations
Objective the care provider’s observations and tests
Assessment the care provider’s understanding of the
problem
Plans goals, action, advice
9. SOAP/IER :-
Intervention when an intervention was
identified and changed to meet client’s needs
Evaluation how outcomes of care are
evaluated
Revision when changes to the original
problem come from revised interventions,
outcomes of care or time lines this is used to
denote changes
10. -:PIE
The PIE notes are numbered or labeled according to
the client’s problems. Resolved problems are
dropped from daily documentation after the RN’s
review. Continuing problems are documented
daily (Potter et al., 2006 )
Problems
Intervention
Evaluation
11. Focus Charting :-
Focus Charting (sometimes referred to as DAR)
This method of documentation consists of notes
that include data, both subjective and objective;
action or nursing interventions; and response of
the client.
Data
Action
Response
12.
13. Type of Diagnosis
physical diagnosis
differential
diagnosis
medical diagnosisclinical diagnosis
diagnosis based on
information
obtained by
inspection,
palpation,
percussion, and
auscultation
the determination of
which one of several
diseases may be
producing the
symptoms
diagnosis based on
information from
sources such as
findings from a
physical
examination,
interview with the
patient or family or
both, medical
history of the
patient and family,
and clinical findings
as reported by
laboratory tests and
radiologic studies
diagnosis based on
signs, symptoms,
and laboratory
findings during life
14. Definition :-
• a statement of a health problem or of a potential
problem in the client's health status that a nurse
is licensed and competent to treat.
• The process of assessing potential or actual
health problems, including those pertaining to an
individual patient, a family or community, that fall
within the scope of nursing practice; a judgment
or conclusion reached as a result of such
assessment or derived from assessment data.
15. Type of nursing diagnosis :-
1- ACTUAL:
It’s referred to the recent problem that the patient is
complaining from it .
Example: Impaired gas exchange r/t status of secretions
associated with difficulty coughing up secretions from
fatigue .
1. Large amounts thick green-yellow sputum
2. Frequent coughing with expectoration of sputum
3. Crackles throughout both lung fields
4. O2 sat of 90 - 87% without oxygen
16. Type of nursing diagnosis :-
RISK:
This diagnosis indicates from the data, a strong
likelihood that it will occur if actions are not
taken.
The Risk diagnosis only has 2 parts. It can be
used with any NANDA diagnosis.
Example: Risk for falls r/t to unsteady gait
17. Type of nursing diagnosis :-
POTENTIAL COMPLICATION:
This is also known as a collaborative diagnosis. This is a
problem the nurse cannot treat independently.
Nursing care will focus on monitoring and preventing the
problem. A collaborative diagnosis can be written as a one
or two part statement.
Example:
P.C. of chronic obstructive pulmonary disease: respiratory
failure
18. REFERENCES :-
• CRNBC Practice Standard Documentation
• www.crnbc.ca/NursingPractice/Requirements.
aspx
• Meadows G. Nursing informatics: An evolving
speciality. Nursing Economic$ 2002;20(6):300–
301. [PubMed]