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The nursing cultural assessment will identify factors that may impede or facilitate the implementation of a nursing diagnosis. Cultural factors have a major impact on the nursing assessment. Some of the information obtained during the interview include: ethnic origin; primary language; second language; the need for an interpreter
In nursing education, a clerkship refers to the clinical courses conducted by students during their final year of studies. The student satisfaction with the clerkship is a determinant factor in selection of nursing field. [9] [10] Physician assistant programs in the United States used the term in the same manner. [11] [12] [13]
An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a patient for signs of disease. The abdominal examination is conventionally split into four different stages: first, inspection of the patient and the visible characteristics of their abdomen.
Boundaries are an integral part of the nurse-client relationship. They represent invisible structures imposed by legal, ethical, and professional standards of nursing that respect the rights of nurses and clients. [3] These boundaries ensure that the focus of the relationship remains on the client's needs, not only by word but also by law.
The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8]
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 ...
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...
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.