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The documentation of nursing assessment is the recording of the process about how a judgment was made and its related factors, in addition to the result of the judgment. It makes the process of nursing assessment visible through what is presented in the documentation content. [4]
For example, the Waterlow score and the Braden scale deals with a patient's risk of developing a Pressure ulcer (decubitus ulcer), the Glasgow Coma Scale measures the conscious state of a person, and various pain scales exist to assess the "fifth vital sign". The use of medical equipment is routinely employed to conduct a nursing assessment.
An example of a health promotion diagnosis is: Readiness for enhanced nutrition. Syndrome diagnosis A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions. An example of a syndrome diagnosis is: Relocation stress syndrome. [11]
This is an accepted version of this page This is the latest accepted revision, reviewed on 6 February 2025. Organized collection of books or other information resources It has been suggested that Multimedia library be merged into this article. (Discuss) Proposed since February 2025. For other uses, see Library (disambiguation). Library patron retrieving a book from a shelf A library is a ...
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.
Notes on Nursing: What it is and What it is Not is a book first published by Florence Nightingale in 1859. [ 1 ] [ 2 ] [ 3 ] A 76-page volume with 3 page appendix published by Harrison of Pall Mall, it was intended to give hints on nursing to those entrusted with the health of others.
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NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA ...