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Wound, ostomy, and continence nursing is a nursing specialty involved with the treatment of patients with acute and chronic wounds, patients with an ostomy (those who have had some kind of bowel or bladder diversion), and patients with incontinence conditions (those with issues of bladder control, bowel control, and associated skin care).
An admission note is part of a medical record that documents the patient's status (including history and physical examination findings), reasons why the patient is being admitted for inpatient care to a hospital or other facility, and the initial instructions for that patient's care.
Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal ...
Another example is the DART system, organized into Description, Assessment, Response, and Treatment. [2] Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.
For example, the word "colostomy" often refers either to an artificial anus or the procedure that creates one. Accordingly, it is not unusual for a stoma to be called an ostomy (plural ostomies ), as is the norm in wound, ostomy, and continence nursing .
Only the proximal stoma is functioning. Most often, double-barrel colostomy is a temporary colostomy with two openings into the colon (distal and proximal). The elimination occurs through the proximal stoma. Colostomy surgery that is planned usually has a higher rate of long-term success than surgery performed in an emergency situation.
The four components of a SOAP note are Subjective, Objective, Assessment, and Plan. [1] [2] [8] The length and focus of each component of a SOAP note vary depending on the specialty; for instance, a surgical SOAP note is likely to be much briefer than a medical SOAP note, and will focus on issues that relate to post-surgical status.
One example is a situation where the cancer tumor is causing a blockage (obstruction). [3] In such a case, the ileostomy may be temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining sections of colon or rectum following removal of the tumor provided that enough of the rectum remains intact to preserve ...