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A nursing care plan promotes documentation and is used for reimbursement purposes such as Medicare and Medicaid. The therapeutic nursing plan is a tool and a legal document that contains priority problems or needs specific to the patient and the nursing directives linked to the problems. It shows the evolution of the clinical profile of a patient.
It is the most widely used nursing model in the United Kingdom. The model is based loosely upon the activities of daily living that evolved from the work of Virginia Henderson in 1966. The latest book edited by these women 2001 is their culminating and completing work, in which they upgrade their model based on their view of societal needs.
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 needs assessment is a systematic process for determining and addressing needs, or "gaps", between current conditions, and desired conditions, or "wants". [ 1 ] Needs assessments can help improve policy or program decisions, individuals, education, training, organizations, communities, or products.
In general terms, the nursing process is the method used to assess and diagnose needs, plan outcomes and interventions, implement interventions, and evaluate outcomes. The nursing process as defined by the American Nurses Association comprises five steps: 1) evaluate, 2) implement, 3) plan, 4) diagnose, and 5) assess.
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]
Recognition of prior learning (RPL), prior learning assessment (PLA), or prior learning assessment and recognition (PLAR) describes a process used by regulatory bodies, adult learning centres, career development practitioners, military organizations, human resources professionals, employers, training institutions, colleges and universities around the world to evaluate skills and knowledge ...
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.