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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.
Cognitive-perceptual-assessment of neurological function is done to assess, check the person's ability to comprehend information; Self perception/self concept; Role relationship—This pattern should only be used if it is appropriate for the patient's age and specific situation. Sexual reproductivity; Coping-stress tolerance; Value-Belief Pattern
A review of systems (ROS), also called a systems enquiry or systems review, is a technique used by healthcare providers for eliciting a medical history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient (as opposed to the objective signs perceived by the clinician).
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] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]
Pain stimulus is a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli (such as shaking of the shoulders). [1]
Romberg's test is not a test of cerebellar function, as it is commonly misconstrued. Patients with severe cerebellar ataxia will generally be unable to balance even with their eyes open; [ 6 ] therefore, the test cannot proceed beyond the first step and no patient with cerebellar ataxia can correctly be described as Romberg's positive.
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.
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 ...