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Nursing Process and Caring Plan
Term | Definition |
---|---|
Assessment | Organized collection of data about a client |
Etiology | Cause |
Interference | Speculating or conjecturing alternatives; making conclusion |
Interview | Meeting at which information is obtained |
Medical Diagnosis | Statement of a present or potential client condition based upon diagnostic procedures |
Nursing care plan | INDIVIDUALIZED plan of action based upon an assessment of the clients needs and designed to meet the specific and general objectives needed for recovery |
Nursing Diagnosis | Statement of a present or potential client problem that requires nursing intervention |
Nursing Process | Systemic method of a course of action which includes assessment, plan, implementation, and evaluation |
Objective | Aim or goal toward which effort is directed |
Objective Data | Data that can be observed |
Priority | Something meriting special attention in advance of other things |
Protocol | A written plan specifying the procedures to be followed for a select clinical condition or situation |
Reflection | Process of thinking back or recalling an event to discover the meaning and purpose of that event |
Scientific Rationale | the reason, based on supporting literature, a specific nursing action was chosen |
Subjective Data | Data the client reports, believes, feels, or what significant other reports |
3 Part Format for Nursing Diagnosis | P- problem E- etiology S- symptoms |
Etiology in Nursing Diagnosis = | Related To (R/T)......... R?T incisional Pain |
AEB in Nursing Diagnosis | Exhibited by or defining characteristics........ AEB restricted turning and repositioning |