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Chapter 2: Clinical Assessment, Reasoning, and Documentation

AB
scientific methodCollection of data through observation, experimentation, and the formulation and testing of a hypothesis
HypothesisScientific guess
Nursing ProcessIncludes, assessment, planning, diagnosis, implementation, and evaluation
AssessmentAnswers the question what is happening?
PlanningWhat are you going to do about the problem?
ImplementationWhat you actually do with the patient to address the problem
EvaluationData analysis of plan and implementation, and patient outcomes
Nursing Diagnosisclinical judgment about individual, family, or community responses to actual, or potential health problems/life processes that requires nursing intervention
Actual DiagnosisStatement about a health problem the client has, and the benefit from nursing care
Risk DiagnosisStatement about health problems that a patient does not have yet, but is at high risk to develop in the near future
Possible DiagnosisStatement about a health problem the patient might have currently, but there is insufficient information currently to make an actual diagnosis
Syndrome DiagnosisUsed when a cluster of nursing diagnosis are seen together
Wellness DiagnosisDescribes an aspect of the client that is at a low level of wellness
ProblemStatement of the patient’s risk for or actual health condition that the nurse is licensed and accountable to treat
EtiologyStatement of the patient’s risk for or actual health condition that the nurse is licensed and accountable to treat
Medical DiagnosisMust be determined by physician, prior to being utilized in nursing diagnosis
ManifestationsSigns and symptoms of the problem identified
PlanWhat are you going to do about this patient’s problem?
ImplementationActual hands on with the patient
EvaluationDetermine whether or not plan actually maintained or increased patient’s level of wellness
Universal Self Care Requisitesbasic and common to all humans and are constantly present; these needs must be met to achieve optimal health and well-being.
Self-Care AgencyAssets or abilities of an individual to perform self-care
Self-Care DeficitDeficit relationship that exists when the demand for self – care exceeds the person’s ability to perform self – care


Health Science Technology Instructor
Carl Wunche High School
Spring , TX

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