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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.
The following diagnostic systems and rating scales are used in psychiatry and clinical psychology. This list is by no means exhaustive or complete. This list is by no means exhaustive or complete. For instance, in the category of depression, there are over two dozen depression rating scales that have been developed in the past eighty years.
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).
An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to the objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on ...
The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and ...
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
A Clinical Decision Support System (CDSS) is a computerized tool designed to assist healthcare providers in making clinical decisions by integrating medical knowledge with patient data. These systems utilize algorithms, databases, and patient information to provide tailored recommendations, alerts, and reminders to healthcare professionals at ...
It makes the process of nursing assessment visible through what is presented in the documentation content. [4] During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client. [5]