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  2. Nursing diagnosis - Wikipedia

    en.wikipedia.org/wiki/Nursing_diagnosis

    Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician's orders (e.g., medication administration). [ 1 ] Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response ...

  3. Nursing assessment - Wikipedia

    en.wikipedia.org/wiki/Nursing_assessment

    Nursing assessment. 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.

  4. Nursing documentation - Wikipedia

    en.wikipedia.org/wiki/Nursing_documentation

    Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting ...

  5. Pain assessment - Wikipedia

    en.wikipedia.org/wiki/Pain_assessment

    The Joint Commission began setting standards for pain assessment in 2001 stating that the route of analgesic administration dictates the times for pain reassessment, as different routes require different amounts of time for the medication to have a therapeutic effect. Oral: 45–69 minutes. Intramuscular: 30 minutes. Intravascular: 15 minutes.

  6. SAMPLE history - Wikipedia

    en.wikipedia.org/wiki/SAMPLE_History

    It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]

  7. Adherence (medicine) - Wikipedia

    en.wikipedia.org/wiki/Adherence_(medicine)

    In medicine, patient compliance (also adherence, capacitance) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care, self-directed exercises, or therapy sessions.

  8. Institute for Safe Medication Practices - Wikipedia

    en.wikipedia.org/wiki/Institute_for_Safe...

    1975. Founder. Michael R. Cohen. Headquarters. United States. Website. www.ismp.org. The Institute for Safe Medication Practices (ISMP) is an American 501 (c) (3) organization focusing on the prevention of medication errors and promoting safe medication practices. [1] It is affiliated with ECRI.

  9. 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. The following areas are assessed through questions asked by the nurse and medical examinations to provide an overview of the individual's health status and ...