Nursing Documentation Handbook / Edition 2

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Overview

This practical guide to 50 frequently encountered problems, their diagnosis and management, includes documentation which will fulfill legal, quality assurance and reimbursement requirements. Alphabetically organized, the book helps identify interventions, data, and outcomes appropriate for specific patients. 336 pp. Pub: 10/95.

"...organized alphabetically, it helps the busy nurse quickly identify interventions,data,& outcomes that may be appropriate & to thoroughly document care using little time ...includes specific suggestions for 38 common conditions."

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Product Details

  • ISBN-13: 9780815164050
  • Publisher: Elsevier Health Sciences
  • Publication date: 9/28/1995
  • Edition description: Older Edition
  • Edition number: 2
  • Pages: 355
  • Product dimensions: 4.78 (w) x 7.38 (h) x 0.73 (d)

Table of Contents

Pt. 1 The Principles of Documentation
1 Documentation: An Overview 3
2 The Patient Record 9
3 Systems of Nursing Documentation 15
4 The Joint Commission on Accreditation of Healthcare Organizations Standards Related to Documentation 20
5 American Nurses Association Standards of Care 31
Pt. 2 Medical-Surgical Care Documentation Guidelines
Acquired Immune Deficiency Syndrome (AIDS) 37
Acute Myocardial Infarction 46
Alzheimer's Disease and Other Dementias 53
Amputation 62
Angina 67
Asthma 74
Brain Tumor 80
Cancer Care 89
Cardiac Surgical Care 98
Cataract Care 107
Cerebrovascular Accident 112
Chemotherapy 121
Chronic Obstructive Pulmonary Disease 131
Congestive Heart Failure 139
Decubitus Ulcer 147
Diabetes Mellitus 154
Dialysis (Peritoneal, Hemodialysis) 162
Diarrhea 170
Enteral Care 176
Fracture Care (Orthopedic Care, Lower Extremity, Hip) 182
Gastrostomy Tube (G-tube) 189
Hypertension 195
Immobile Patient 200
Impaction 208
Intestinal Obstruction 212
Intravenous Therapy Care 218
Mastectomy Care 223
Osteoarthritis 231
Ostomy 238
Pain Management 246
Peripheral Vascular Disease 251
Pneumonia 257
Sickle Cell Anemia 263
Surgical Care 270
Tracheostomy Care 279
Tuberculosis (TB) 287
Urinary Catheter Care 294
Wound Care 299
Pt. 3 Hospice Care Documentation Guidelines
Hospice Care 307
App. A: 1995 NANDA-Approved Nursing Diagnoses 317
App. B: Services Provided by Other Disciplines 321
App. C: Abbreviations 326
Bibliography 333
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