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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.
A nursing care component is defined as a cluster of elements that represents a unique pattern of clinical care nursing practice; namely, Health Behavioral, Functional, Physiological, and Psychological. Nursing Diagnoses: A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs.
Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. [8] In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality's focus such as nursing, physical therapy, etc.
The greatest single distinguishing feature of team nursing is the team conference. In general, there are three parts to the conference; Report by each team member on his or her patients. Planning for new patients and changing plans as needed for others. Planning the next day’s assessment.
SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing. Uses [ edit ]
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 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 ...
The Global Appraisal of Individual Needs (GAIN) is a family of evidence-based instruments used to assist clinicians with diagnosis, placement, and treatment planning. The GAIN is used with both adolescents and adults in all kinds of treatment programs, including outpatient, intensive outpatient, partial hospitalization, methadone, short-term residential, long-term residential, therapeutic ...