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  2. Clinical Care Classification System - Wikipedia

    en.wikipedia.org/wiki/Clinical_Care...

    A nursing intervention is defined as a single nursing action – treatment, procedure or activity – designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable. [12] Patient services are usually initiated as medical orders by a referring physician and reviewed by the admitting nurse.

  3. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/Nursing_diagnosis

    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 ...

  4. Nursing Outcomes Classification - Wikipedia

    en.wikipedia.org/wiki/Nursing_Outcomes...

    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 ...

  5. Early warning system (medical) - Wikipedia

    en.wikipedia.org/wiki/Early_warning_system_(medical)

    An early warning system (EWS), sometimes called a between-the-flags or track-and-trigger chart, is a clinical tool used in healthcare to anticipate patient deterioration by measuring the cumulative variation in observations, most often being patient vital signs and level of consciousness. [1]

  6. Gordon's functional health patterns - Wikipedia

    en.wikipedia.org/wiki/Gordon's_functional_health...

    Manual of Nursing Diagnosis - Eleventh Edition. ... ISBN 0-7637-4045-4 This page was last edited on 1 September 2024, at 21:58 (UTC). Text is available under the ...

  7. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    [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] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]

  8. NANDA International - Wikipedia

    en.wikipedia.org/wiki/NANDA_International

    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.

  9. Progress note - Wikipedia

    en.wikipedia.org/wiki/Progress_note

    Physician documentation is then usually included in the patient's chart and used for medical, legal, and billing purposes. Nurses are required to generate progress notes on a more frequent basis, depending on the level of care and may be required anywhere from several times an hour to several times a day.