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  2. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/Nursing_diagnosis

    Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). [1] Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response ...

  3. Confusion Assessment Method - Wikipedia

    en.wikipedia.org/wiki/Confusion_Assessment_Method

    The Confusion Assessment Method (CAM) is a diagnostic tool developed to allow physicians and nurses to identify delirium in the healthcare setting. [1] It was designed to be brief (less than 5 minutes to perform) and based on criteria from the third edition-revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) .

  4. Delirium - Wikipedia

    en.wikipedia.org/wiki/Delirium

    Delirium (formerly acute confusional state, an ambiguous term that is now discouraged) [1] is a specific state of acute confusion attributable to the direct physiological consequence of a medical condition, effects of a psychoactive substance, or multiple causes, which usually develops over the course of hours to days.

  5. Nursing process - Wikipedia

    en.wikipedia.org/wiki/Nursing_process

    The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...

  6. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting nurse.

  7. Altered level of consciousness - Wikipedia

    en.wikipedia.org/wiki/Altered_level_of_consciousness

    Confused: Disoriented; impaired thinking and responses People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "confused". [8] A confused person may be bewildered, disoriented, and have difficulty following instructions. [9] The person may have slow thinking and possible memory time ...

  8. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  9. Gordon's functional health patterns - Wikipedia

    en.wikipedia.org/wiki/Gordon's_functional_health...

    Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.