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nursing

is an art of applying scientific principles in a humanitarian way to care of people.

health assessment

is an essential nursing function which provides foundation for quality nursing care and intervention.

Nursing process

serves as the organizational framework for the practice of nursing.

diagnosis

It is the determination of the nature and extent of a disease.

prognosis

It is the forecast of the course and duration of a disease.

etiology

It is the science of the cause of a disease

signs

The presence of a disease that can been seen or elicited e.g. Fever.

symptoms

Any evidence as to the nature and location of a diseases noted by the client.

assessment

is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter.

assessment

It is a deliberate, systematic and logical collection of subjective and objective data

subjective data

What the patient tells you.

objective data

signs or overt cues are observable, perceptible and measurable data during physical examination

primary source

is the client himself

secondary source

are the health sources include family members or significant others, health record,

diagnosis

This is the second phase of the nursing process. involves a nurse making an educated judgment about a potential or actual health problem with a patient.

diagnostic label

is the name of the nursing diagnosis. eg: stress incontinence

qualifiers

are words used to give additional meaning to a nursing diagnosis. eg: altered, impaired

definition

describes the characteristics of the human response under consideration

defining characteristics

are major and minor clinical cues that validate the presence of an actual nursing diagnosis.

risk factors

are identifiable intrinsic and extrinsic characteristics of the client. E.g. risk for infection.

related factors

they describe the conditions, circumstances or etiologies that contribute to the problem. E.g. fluid volume deficit related to vomiting.

problem focused

also known as actual diagnosis

health promotion diagnosis

also known as wellness diagnosis
is a clinical judgment about motivation and desire to increase well-being.

risk nursing diagnosis

These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

syndrome diagnosis

cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event.

implementation

action phase of the nursing process.

independent

any action the nurse can initiate without direct supervision

dependent

nursing actions requiring MD orders

collaborative

nursing actions performed jointly with other health care team members

evaluation

last phase of the nursing process
This step determine the success/effectiveness of the whole nursing process and the decision either to continue, modify or repeat the process is depend on evaluation.

INITIAL COMPREHENSIVE ASSESSMENT

is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status.

ONGOING ASSESSMENT

Systematic monitoring of specific problems

EMERGENCY ASSESSMENT

During any physiologic and psychologic crisis of the patient.

FOCUSED OR PROBLEM ORIENTED ASSESSMENT

A problem focus assessment collects data about a problem that has already been identified.