Esme12

In my experience "I/S/O" has meant "In the Setting Of", but that may not be the case across the board. One of the reasons there are approved abbreviations which this practitioner has decided not to follow.
Another potential use case would be  "In Search Of".

As others have said, the most logical answer is Worst Headache of  the (patient's) Life.

That said, this is the reason non-approved abbreviations should not be used in official charting.

You start at the beginning...the patient history, diganoses, meds, labs assessment. Describe the disease processes in detail and how they may or may not contribute to the issue at hand.
I have not seen this worred this way I would seek clarification from your program as to the expectations for this paper....to me it sounds like a case study. Maybe I am just obtuse but I don't understand what is needed

I know that in some facilities places like NICU or immune-compromised patients nurses with cold sores are not permitted to work. Some if it is draining you are not permitted to work. Most require a mask if in direct contact.

We do EKG within 10, heploc, O2, ENCASA (Someplaces I have worked go for chewable ASA), SL nitro x3. Full cardiac profile w troponin, full coag profile. CXR. If unrelieved EKG and start IV nitro with MD approval. Further Rx pending immediate MD eval.

Medical abbreviation for rule out.
It means they were admitted with R/O CVA, R/O OSA
The MD is still considering a CVA however the CT is negative, the patient has no residual neuro deficit and the confusion has resolved.
R/O OSA is still a consideration as well....and further testing is being conducted.

FDAR charting: Focus Data Action Response. FOCUS CHARTING- describes the patient's perspective and focuses on documenting the patient's current status, progress towards goals, and response to interventions.
Focus– identifies the content or purpose of the narrative entry and is
separated from the body of the notes in order to promote easy data retrieval and communication
Data - statements contain objective and/or subjective information.
Action– statements that contain nursing interventions (basic, perspective,independent) past, present or future.- it also contains collaborative orders
Response– Evident patient outcomes or response
INFORMATION FROM ALL THREE CATEGORIES (DATA,ACTION,RESPONSE)should be used only as they are RELEVANT or AVAILABLE.However, all appropriate information should be included to ensure complete documentation
Purpose of FDAR charting
1) To easily identify critical patient issues/concerns in the Progress Notes.
2) To facilitate communication among all disciplines.
3) To improve time efficiency with documentation.
4) To provide concise entries that would not duplicate patient information already provided on flow sheet/checklist.When is FDAR necessary
5) To describe a patient problem/ focus/ concern from the care plan
6) To document an activity or treatment that was carried out
7) To document a new findings
8) To document an acute change in patient's condition
9) To identify the discipline making the entry as well as the topic of the note
10) To describe all specifics regarding patient/family teaching
11) To document a significant event or unusual episode in patient care
DOCUMENTATION DO’S AND DONT’S
-DO time and date all entries.
-DO use flowsheet/ checklist. Keep information on flowsheet/checklist current
-DO chart as you make observations.
-DO write your own observations and sign your own name. Sign and initial every entry.
-DO describe patient's behavior and use direct patient quotes when appropriate.
-DO record exactly what happens to patient and care given.
-DO be factual and complete.
-DO draw a single line thru an error. Mark this entry as “error and-sign your name.”
-DO use only approved abbreviations-DO use next available line to chart.
-DO document patient's current status and response to medical care and treatments.
-DO write legibly. DO use ink. DO use accepted chart forms.
DONT’S
-DON'T begin charting until you check the name and identifying number on the patient's chart on each page.
-DON'T chart procedures or cares in advance.
-DON'T clutter notes with repetitive or frequently changing data already charted on the flowsheet/checklist.
-DON'T make or sign an entry for someone else.
-DON'T change and entry because someone tells you.
-DON'T label a patient or show bias.
-DON'T try to cover up a mistake or incident by inaccuracy or omission.
-DON'T “white out” or erase an error.
-DON'T throw away notes with an error on them.
-DON'T squeeze in a missed entry or “leave space” for someone else who forgot to chart.
-DON'T write in the margin.
-DON'T use meaningless words and phrases, such as “good day”or “no complaints”-
-DON'T use notebook paper or pencil.
GENERAL GUIDELINES
-Focus charting must be evident at least once every shift.
-Focus charting must be patient-oriented not nursing task-oriented.
-Indicate the date and time of entry in the first column.
-Separate the topic words for the body of notes:a. Focus note written on the second column.b. Data, Action and Response on the third column.
-Sign name for every time entry-Document only patient’s concern and/or plan of care e.g. healthteaching per shift.

Intra-abdominal abscess
An intra-abdominal abscess is a pocket of infected fluid and pus located inside the belly (abdominal cavity). there may be more than one abscess.
Causes, incidence, and risk factors
An intra-abdominal abscess can be caused by a ruptured appendix, ruptured intestinal diverticulum, inflammatory bowel disease, parasite infection in the intestines (entamoeba histolytica), or other condition.
Risk factors include a history of appendicitis, diverticulitis, perforated ulcer disease, or any surgery that may have infected the abdominal cavity.
Symptoms
depending on the location, symptoms may include:
abdominal pain and distention chills diarrhea fever lack of appetite nausea rectal tenderness and fullness vomiting weakness Signs and tests
A complete blood count may show a higher than normal white blood count. a comprehensive metabolic panel may show liver, kidney, or blood chemistry problems.
A ct scan of the abdomen will usually reveal an intra-abdominal abscess. after the ct scan is done, a needle may be placed through the skin into the abscess cavity to confirm the diagnosis and treat the abscess.
Other tests may include:
abdominal x-ray ultrasound of the abdomen Treatment
Treatment of an intra-abdominal abscess requires antibiotics (given by an IV) and drainage. Drainage involves placing a needle through the skin in the abscess, usually under x-ray guidance. The drain is then left in place for days or weeks until the abscess goes away.
Occasionally, abscesses cannot be safely drained this way. in such cases, surgery must be done while the patient is under general anesthesia (unconscious and pain-free). a cut is made in the belly area (abdomen), and the abscess is drained and cleaned. a drain is left in the abscess cavity, and remains in place until the infection goes away.
It is always important to identify and treat the cause of the abscess.
Expectations (prognosis)
The outlook depends on the original cause of the abscess and how bad the infection is. generally, drainage is successful in treating intra-abdominal abscesses that have not spread.
Complications
Potential complications include:
return of the abscess rupture of an abscess spread of the infection to the bloodstream widespread infection in the abdomen What are they complaining of, what antibiotics are they on? Why are they still there? Care plan basics:
Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what NANDA calls defining characteristics.
How does a doctor diagnose? They thoroughly review medical history and perform a physical examination first. Nurses do that too, it's part of step #1 of the nursing process.
Only then, does he use "medical decision making" to ferret out the symptoms the patient is having and determine which medical diagnosis applies in that particular case.
Each medical diagnosis has a defined list of symptoms that the patient's illness must match. Nurses do that too! We call it "critical thinking" and it's part of step #2 of the nursing process. The NANDA taxonomy lists the symptoms that go with each nursing diagnosis.
Nursing Process
Assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology) Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use) Planning (write measurable goals/outcomes and nursing interventions) Implementation (initiate the care plan) Evaluation (determine if goals/outcomes have been met) A care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. The nursing process itself is a problem solving method that was extrapolated from the scientific methods used by the various science disciplines in proving or disproving theories.