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IN NURSING PRACTISE
• Some examples
- “Patient going into shock, could not reach Dr. Jones per usual”
- Physician Note, “Once again the lab forgot to draw the patient’s
PTT this am”
Do's…..
• Chart patient care at the time you provide it.
Don'ts
• Don't chart a symptom, such as "c/o pain," without
also charting what you did about it.
• Don't use shorthand or abbreviations that aren't widely
accepted.
• Don't write imprecise descriptions, such as "a large
amount."
Students task
Nursing Diagnosis
• Imbalance nutrition : less than body
requirement related to inadequate intake of
nutrition.
• Ineffective airway clearence related to tracheo-
bronchial obstruction
• Anxiety related to change in health status and
situational crisis.
Do the task according to the nursing
diagnose above :
• Make a nursing care plan first and then make a
documentation of implementation according to
the nursing care plan.
• Make at least 3 documentation for each nursing
diagnose
• Do it as handwriting in a paper and then collect
it.
• That’s all.