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  2. 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 ...

  3. SOAP note - Wikipedia

    en.wikipedia.org/wiki/SOAP_note

    A medical diagnosis for the purpose of the medical visit on the given date of the note written is a quick summary of the patient with main symptoms/diagnosis including a differential diagnosis, a list of other possible diagnoses usually in order of most likely to least likely. The assessment will also include possible and likely etiologies of ...

  4. Gordon's functional health patterns - Wikipedia

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

    Gordon’s functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.

  5. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    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]

  6. Clinical Care Classification System - Wikipedia

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

    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 ...

  7. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    The nursing cultural assessment will identify factors that may impede or facilitate the implementation of a nursing diagnosis. Cultural factors have a major impact on the nursing assessment. Some of the information obtained during the interview include: ethnic origin; primary language; second language; the need for an interpreter

  8. Effective therapeutic regimen management - Wikipedia

    en.wikipedia.org/wiki/Effective_therapeutic...

    As such, the diagnoses selected for the volume are not exhaustive, but represent a severely underdeveloped knowledge base. We have chosen diagnoses that are most prevalent, most difficult to treat, and/or most in need of further development to inform practicing nurses and nursing students and to improve the quality of life of older persons.

  9. Nursing process - Wikipedia

    en.wikipedia.org/wiki/Nursing_process

    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.