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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
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
Self-diagnosis is the process of diagnosing, or identifying, medical conditions in oneself.It may be assisted by medical dictionaries, books, resources on the Internet, past personal experiences, or recognizing symptoms or medical signs of a condition that a family member previously had or currently has.
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 ...
The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patients assessment. Multiple nursing diagnoses may be made for one client.
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 ...
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 computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]