The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the…

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview,…

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The…

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care…

Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more…

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording…

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient…

A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent…

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused,…

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out…

Improving patient education focusing on bowel preparation before a colonoscopy leads to cleaner colons. Endoscopy units must obtain informed consent…

Diabetes mellitus is a major independent risk factor for increased morbidity and mortality in the hospitalized patient, and elevated blood glucose…

TBase is an electronic health record (EHR) for kidney transplant recipients (KTR) combining automated data entry of key clinical data (e.g.,…