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Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides.
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 present-day concept of advanced practice nursing as a primary care provider was created in the mid-1960s, spurred on by a national shortage of physicians. [7] The first formal graduate certificate program for NPs was created by Henry Silver, a physician, and Loretta Ford, a nurse, in 1965. [7]
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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.
Pocket Ref is a general-purpose pocket-sized reference book composed of various tips, tables, maps, formulas, constants and conversions, compiled by Thomas J. Glover. [1] It is published by Sequoia Publishing, and is currently in its fourth edition at 864 pages in length, released in late 2010.
A biophysical profile (BPP) is a prenatal ultrasound evaluation of fetal well-being involving a scoring system, [1] with the score being termed Manning's score. [2] It is often done when a non-stress test (NST) is non reactive, or for other obstetrical indications.
The Nursing Minimum Data Set (NMDS) is a classification system which allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. The NMDS allow for the analysis and comparison of nursing data across populations ...