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The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...
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 ...
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 ...
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization.
Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of a plan to achieve expected outcomes. Registered nurses utilize nursing and medical diagnoses depending upon education and clinical preparation and legal ...
It makes the process of nursing assessment visible through what is presented in the documentation content. [4] 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]
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It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses.