nursing skills chpt 2

an organized sequence of problem-solving steps used to identify and to manage the health problems of clients

an independent problem-solving role that involves the diagnosis and treatment of human responses to actual or potential health problems

a process of objective reasoning or analyzing facts to reach a valid conclusion

• observable and measurable facts;
• also known as signs

• consists of information that only the client feels and can describe;
• also known as symptoms

initial information about the client's physical,emotional, social, and spiritual health

serves as a reference point for comparing all future data andf identifies the client's initial problems

information that provides more details about specific problems and expands the original data base

usually repeated frequently to determine trends

developes and approves nursing diagnosis terms

physiologic complications that require both nurse- and physician- prescribed interventions

the process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan of care