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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 nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing ...
Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health.
The nursing directives can be addressed to nurses, nursing assistants or beneficiary attendants. Each priority problem or need must be followed by a nursing directive or an intervention. The interventions must be specific to the patient. For example, two patients with the problem 'uncooperative care' can need different directives.
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.
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...
This knowledge can be in the form of research or national guidelines for example. With problem focus, nurses can find room for improvement from already existing facts. Second, clinical application is how nurses figure out the importance of the question identified and the relevance by using the EBP process.
Assessment (either summative or formative) is often categorized as either objective or subjective. Objective assessment is a form of questioning which has a single correct answer. Subjective assessment is a form of questioning which may have more than one correct answer (or more than one way of expressing the correct answer).