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Text Free Browsing does what the name says: once you install it, you can click on a little nerdy face to turn off all text on the internet. Contact us with a description of the clipart you are searching for and we'll help you find it. You just have to choose a template, rewritte your own message over the original text, download full color diploma (high quality PDF file) and print. Documentation is an integrated component of the process of developing a nursing care plan that is initiated by the appropriate nursing personnel.
For demonstration purposes, the abbreviated medical history below is appropriate for all examples (Figs. Figure AppD-1A addresses the three major NANDA diagnoses, which are numbered in the NANDA Diagnosis column. Each NANDA diagnosis would be addressed separately using the APIE format based upon the nursing assessment, the care plan, and the NANDAs.
With charting by exception, the nurse generally starts by working with a standard systems flow sheet (Fig. Figure AppD-5 shows a graphic flow sheet that indicates multiple areas of routine charting.


FIGURE 2 · Example of problem area (focus) charting: SOAP (subjective, objective, analysis, plan). FIGURE 3 · Example of problem area (focus) charting: APIE (assessment, problem, implementation, evaluation).
Computerized templates of forms or hard copy pen-and-paper preprinted forms can be used, depending on the individual facility needs, resources, and requirements. The documentation is written as a narrative as the events occurred (ie, narrative chronological charting). For instructional purposes using this example, the NANDA diagnoses are also in bold italics within the charting. At the time of the collection of data, the nurse also discovers significant abnormal findings related to nausea, abdominal distention, and pain. AppD-4A), which indicates most normal findings according to body system (neurologic, cardiovascular, and so forth) or other organized, preprinted format. Gastrointestinal tissue perfusion ineffective related to mechanical blockage of peristalsis as manifested by hyperactive bowel sounds RUQ, absent bowel sounds in remaining quadrants, and acute, severe abdominal pain and nausea. Nursing diagnoses (NANDAs) are integral parts of the nursing process and need to be reflected in your facility’s documentation and record-keeping formats.


The NANDA diagnoses are developed from this medical history and from an initial comprehensive admission nursing assessment, which is not provided here.
Notice  how the numbered NANDAs, from the abbreviated medical history above, are integrated into the assessment. Other ways of documenting charting errors are to write recorded in error or mistaken entry and your initials.
The basic nursing process consists of the assessment, identification of NANDAs, plans with specific goals, interventions or implementations, and the evaluation of each plan or goal. Her history includes a cerebrovascular accident 2 years ago, resulting in weakness of the left leg.
She was admitted to the acute care facility 2 days ago with a diagnosis of left lower lobe pneumonia.



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