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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

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