18 terms

The Nursing Process

Objective data
observable and measurable facts and are referred to as signs of a disorder (weight, temp, skin color)
Subjective data
information that only the client feels and can describe, are called symptoms (pain, depression, anxiety)
Data base assessment
initial information about the client's physical, emotional, and spiritual health, lengthy and comprehensive
Focus assessment
information that provides more details about specific problems and expands the original data base
Nursing process
an organized sequence of problem-solving steps used to identify and manage the health problems of clients
Steps of the nursing process
assessment, diagnosis, planning, implementation, evaluation
Nursing diagnosis
a health issue that can be prevented, reduced, resolved or enhanced through independent nursing measures
Actual diagnosis
a problem that currently exists - "problems with fatigue"
Risk diagnosis
a problem the client is uniquely at risk for developing - "at risk for skin breakdown"
Possible diagnosis
a problem may be present, but requires more data collection to rule out or confirm its existence
Syndrome diagnosis
cluster of problems predicted to be present because of an event or situation
Wellness diagnosis
a health-related problem with which a healthy person obtains nursing assistance to maintain or perform at a higher level
Diagnostic statement
NANDA, etiology (its cause), and signs and symptoms - (Disturbed sleep pattern related to excessive intake of coffee as manifested by difficulty falling asleep and feeling tired during the day).
Short term goal
outcomes achievable in a few days or one week, client-centered
Long term goal
Desirable outcomes that take weeks of months to accomplish for clients with chronic health problems
Maslow's hierarchy of needs
physiology, safety & security, love & belonging, self esteem, self actualization
The nursing process
is an organized sequence of problem-solving steps used to identify and to manage the problems of clients
Six characteristics of the nursing process
within the legal scope of nursing, based on knowledge, planned, client-centered, goal-directed, prioritized, dynamic