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A clinical documentation guide for medical and surgical nurses

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This document provides a comprehensive guide to clinical documentation in medical and surgical nursing. It covers the importance of clinical documentation, the different types of clinical documentation, and the principles of effective clinical documentation. Principles: Accuracy, clarity, completeness, timeliness, and confidentiality are the key principles of effective clinical documentation. This section will explain each principle in detail. Types: Nursing assessments, nursing diagnoses, nursing interventions, patient education, medication administration records, and wound care documentation are the main types of clinical documentation used in medical and surgical nursing. The step-by-step guide will explain how to create and update clinical documentation in a systematic and efficient way. It will cover the steps for collecting and recording data, analyzing and interpreting data, developing and implementing a plan of care, and evaluating the effectiveness of the plan of care. It will also cover how to document changes in the patient's condition, and how to ensure that documentation is complete and accurate.

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MEDICAL SURGICAL NURSING NOTES BY HANEEFA MOMOH

1.1 MEDICAL-SURGICAL NURSING

Medical-surgical nursing is a type of nursing that focuses on providing care to patients who
have a variety of medical conditions and surgical procedures. This type of nursing is usually
done in a hospital setting, but it can also be done in other settings, like long-term care
facilities or home care settings. Medical-surgical nurses work with patients of all ages, and
they often collaborate with other healthcare professionals, like doctors, social workers, and
physical therapists.
So, medical-surgical nurses work with patients who have a wide range of conditions and
procedures. Some common conditions that medical-surgical nurses might work with include
heart disease, cancer, diabetes, and respiratory disorders. Some common procedures that
medical-surgical nurses might be involved with include surgeries, wound care, and
intravenous (IV) therapy.




1.2 DIFFERENT TYPES OF PATIENTS THAT MEDICAL-SURGICAL NURSES MAY
WORK WITH


-ADULT PATIENTS: Adult patients can be divided into three different categories: acute,
chronic, and critical. Acute patients are those who have a sudden or short-term illness or
injury. Chronic patients are those who have a long-term illness or injury that requires ongoing
care. And critical patients are those who are in a life-threatening situation.


-ACUTE PATIENTS: Acute patients can present with a variety of illnesses or injuries, such
as infections, fractures, or acute pain. The goal of care for acute patients is to stabilize their
condition and get them back to their previous level of health as quickly as possible. In terms
of nursing care, acute patients often require close monitoring, medication administration, and
a variety of treatments.


-CHRONIC PATIENTS: Chronic patients can have a wide range of illnesses or injuries, such
as diabetes, arthritis, and chronic pain. Because their illness or injury is long-term, the goal
of care for chronic patients is to manage their condition over time. This means that nurses
need to educate patients and their families about their condition, as well as help them
develop coping strategies.


-CRITICAL PATIENTS: Critical patients are those who are in the most serious condition, and
their life is at risk. Critical patients can be in a coma, have multiple organ failure, or be on life
support. The goal of care for critical patients is to keep them alive, and nurses need to be
constantly vigilant to ensure that their condition doesn't deteriorate.

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Uploaded on
October 11, 2023
Number of pages
3
Written in
2023/2024
Type
Lecture notes
Professor(s)
Haneefa momoh
Contains
Medical and surgical nursing

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