Information obtained through the senses and hands on physical examination
Cues
pieces of data or information that influence decisions
Interferences
Conculsions made based on observed data
Nursing diagnosis
Indicated the patient's actual health status or the risk of a problem developing, the causative or related factors, and specific defining characteristics (signs and symptoms)
Etiologic factors
Causes of the problems
Signs
Abnormalities that can be verified by repeat examination and are objective data
Symptoms
Data the patient has said are occurring that cannot be verified by examination; subjective data
Defining characteristics
Characteristics that must be present for a particular nursing diagnosis to be appropriate for that patient
Goal
Broad idea of what is to be achieved through nursing intervention
Expected outcome
Specific statement of the goal the patient is expected to achieve as a result of nursing intervention