| Term | Definition |
|---|
| 5 Step Nursing Process | Assessment, Diagnosis, Planning, Implementation, Evaluation |
| Assessment | Gather info about the clients condition |
| Diagnose | Identify the clients problem |
| Plan & Identify Outcome | Set goals of care and desired outcomes and identify appropriate nursing actions |
| Implement | perform the nursing actions identified in planning |
| Evaluate | determine if goals met and outcomes achieved |
| objective data | observable and measurable signs |
| subjective data | verbal statements |
| cue | synonym for subjective and objective data |
| biographic data | facts or events in a persons life |
| primary source | patient |
| secondary source | family members, MD, |
| methods of data collection | interview and physical exam |
| Significant cues in nursing | deviations from population norms, change in pts usual health, developmental delays, dysfunctional behavior, changes in usual behavior |
| nursing diagnosis components | title/label, definition of title/label. contributing factors, defining characterisitcs |
| nursing interventions | activities that should promote achievement of desired patient outcome |
Combine with other sets
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