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More recently, she states that health is the process of being and becoming an integrated and whole person. [1] Roy's goal for nursing is "the promotion of adaptation in each of the four modes, thereby contributing to the person's health, quality of life and dying with dignity". [1]
A case presentation is a formal communication between health care professionals such as doctors and nurses regarding a patient's clinical information. [ 1 ] [ 2 ] [ 3 ] Essential parts of a case presentation include:
A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
The information contained in the medical record allows health care providers to determine the patient's medical history and provide informed care. The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care.
AEIOU-TIPS is a mnemonic acronym used by some medical professionals to recall the possible causes for altered mental status.Medical literature discusses its utility in determining differential diagnoses in various special populations presenting with altered mental status including infants, [1] children, [2] adolescents, [3] and the elderly. [4]
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The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes.
Vital signs (also known as vitals) are a group of the four to six most crucial medical signs that indicate the status of the body's vital (life-sustaining) functions. These measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery.