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10 Cards in this Set

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