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All the terminology used should be appropriate. Correct spellings are also necessary and conclusions must not be vague. Moreover, consistency in charting the medical record is necessary. The workups should follow the accepted documentation standards. All the test results and treatment programs entail logical presentation. In addition, objectivity throughout the gathering and interpretation of facts is very important (Marcinko & Hetico, 2011).
Typed notes are mostly preferred but not mandatory. The medical record should read as if the documentation was meant for a third party. Therefore, everybody should be able to read the handwriting. If there is a mistake in the records, one should struck through the error once and then initial his/ her name. The errors are not supposed to be erased, scratched out or blacked out. One should not write on the margins as well. The chart should appear orderly, clean and professional (Marcinko & Hetico, 2011).
Both the art and the science of nursing is essential in conducting health assessments and physical examinations. Critical thinking and clinical reasoning are essential in physical assessment of a patient (Estes, 2013). When conducting a physical exam, noting the vital signs is important in giving clues to the individual’s overall health. The lung and thorax examination should include an assessment of any allergy symptoms experienced by the patient. Chest examinations include assessment of breathing sounds. The respiratory rate and the rhythm are also examined. The skin may be examined to find out if an allergic component is at work using evidenced by presence of a rush. Moreover, it is very important to measure the volume of air going in and out of the lungs, the speed of movement of the air and the volume of the air that is moving to identify or rule out other respiratory disease (Clark, 2011).
Pre and post bronchodilator tests entail proper application to rule out more respiratory maladies. The patient completes a basic
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Jones is a widow of eighty years old and resides alone. She and her next door neighbour used to visit the social club frequently as a leisure activity to play bingo. However, the lifestyle enjoyed by Mrs. Jones got disrupted after she was diagnosed with the problem of falls, sever osteo-arthritis and a hip replacement need.
He is thin as his appetite is poor and he has become increasingly frailer in the last few months.
One cold November day, Mr. Jones is admitted to your ward. On admission he is very dyspnoic at rest with a respiratory rate of 28 breaths per minute. He has a temperature of 37.8 C.
rette smoke that results to the production of large amount of mucous accompanied by wheezing, shortness of breathing, and tightening of the chest (Torpy, et. al., 2008; GOLD, 2008; National Lung Heart and Heart Blood Institute, 2009). COPD is a clinical syndrome of continual
History of mild cold and cough present. No history of altered sensorium, seizures,loose stools or burning micturition.
Past history: Alison is a known patient of End-Stage Renal Failure or ESRF secondary to hypertension and type-2
10, but will cause nearly 30% of all cancer deaths.” Bronchogenic carcinoma remains a challenge to the medical research and, due to the nature of the disease, the survival rate among the patients has not been improved effectively even under reasonably good standards of
It uses rhythmic and repeated contractions to conduct this function. The main components of the heart are the connective tissue and the cardiac muscle that has the ability to pump blood (Kaminsky, 2011). This muscle apparently works involuntarily.
The rationale for using this theory is that it has been fully detailed and explained to fit into the Mr. Tan situation. In addition to that, the pain assessment tool shall be used to justify the assessment. As such, Mr. Tan’s nursing needs which
The condition may also be as a result of increased secretions, thick viscous, retained secretions as well as secreting bloody mucus, which of all are caused by prolonged smoking by the patient.
Activity intolerance is a condition in which Ann suffers from
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