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10 Cards in this Set
- Front
- Back
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Acutal Nursing Diagnosis
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Nursing diagnosis that indicates that a problem exists; composed of the diagnosctic label, related factors, and signs and symptoms
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Analysis
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Breaking down the whole into parts that can be examined.
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Assessment
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First step in nursing process; includes systematic collection, verification, organization, interpretation, and documentation of data.
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Assessment model
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Framework that provides a systematic method for organizing data.
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Assign
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To designate for a prupose or task.
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Charting by exception
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Documentation method that requires the nurse to document only deviations from preestablished norms.
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Comprehensive assessment
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Type of assessment that provides baseline client data, including a complete health history and current needs assessment.
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Confidential
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Nondisclosure of client conversations, documentations, and health information
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Critical pathway
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Comprehensive, standard plan of care for specific case situations.
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Data clustering
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Process of putting data together in order to identify areas of the client's problems and strengths.
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