By Helen C. Cox RN C EdD FAAN, Mittie D. Hinz MSN MBA, Susan A. Newfield PhD RN PMHCNS-BC, Donna Scott-Tilley PhD RN CNE
Organized by means of Gordon’s useful future health styles, this precise care plan textual content is filled with amazing features—it’s the source scholars will flip to time and again. They’ll locate every little thing they should create and enforce nice care plans around the lifespan.
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Davis’s Care making plans & Nursing prognosis source Center
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Additional info for Clinical Applications of Nursing Diagnosis: Adult, Child, Women's, Psychiatric, Gerontic, and Home Health Considerations
Davis. Nursing Process Steps Data Grouping Data grouping simply means organizing the information into sets or categories that will assist you in identifying the patient’s strengths and problem areas. , Roy, Levine, and Orem)40,41 speaks to assessment within the framework of her theories. Organizing the information allows you to both identify the appropriate functional health pattern and to spot any missing data. If you cannot identify the pertinent functional health pattern, then you need to collect further data.
A. Davis. Copyright © 2007 • • 12 • Introduction The POR with its SOAPIER progress note emphasizes the problem-solving component within the nursing process and provides documentation of the care provided. For further information about the POR system, you are directed to the Weed17 reference. FOCUS charting, which is actually an offshoot of POR, is a documentation system that uses the nursing process to document care. Unlike the interdisciplinary POR, FOCUS charting is entirely oriented to nursing documentation.
In essence, the written nursing actions can give an outline for documentation. Properly written nursing actions demonstrate to the nurse both nursing actions and documentation to be done. Referring to the preceding example, we can see that the nurse responsible for this patient’s care should chart the patient’s blood pressure (BP), pulse (P), and respiration (R) rates prior to the activity, the patient’s BP, P, and R rates after the activity, the presence or absence of vertigo, the presence or absence of pain, and the results of a circulatory check.