Chapter 4
Systematically gathering information about a patient’s health through observation, interviews, physical examination, records, and test results.
Assessment
Choosing a course of action after considering available options and their likely consequences.
Decision-making
A broad statement describing the desired improvement in the patient’s health or functioning.
Goal
Experiences of a health problem felt and reported by the patient, such as dizziness, pain, or fatigue.
Symptoms
Signs, symptoms, and other assessment findings that support a particular problem-focused nursing diagnosis.
Defining characteristics
A conclusion about a patient’s needs or problems and whether to take action, based on assessment, nursing knowledge, and reasoning.
Clinical judgment
Specific, measurable patient results expected after nursing care, usually with a stated time frame.
Outcomes
Setting priorities, establishing expected outcomes, and selecting nursing interventions to address the patient’s identified needs.
Planning
A specific, measurable result the patient is expected to achieve within a stated time after receiving care.
Expected outcome
Information reported by the patient or another person about feelings, experiences, or concerns, such as pain or nausea.
Subjective data
Comparing the patient’s actual response with expected outcomes to determine whether care was effective and whether the plan needs revision.
Evaluation
Carefully examining information, questioning assumptions, and using evidence and logic to reach sound conclusions.
Critical thinking
The part of a nursing diagnosis that names the patient’s identified problem or response requiring nursing care.
Problem statement
A purposeful conversation used to gather information about the patient’s health, concerns, experiences, and needs.
Interview
Pieces of information that suggest a patient’s condition, needs, or possible problems and guide further assessment.
Cues
Organizing and interpreting assessment information to recognize patterns, identify actual or potential problems, and determine nursing care needs.
Data analysis/problem identification
A systematic way to investigate a question through observation, a proposed explanation, testing, analysis, and conclusions.
The collection of information about a patient’s health, including the history, assessment findings, and relevant test results.
Database
Organizing and interpreting collected information to identify patterns, draw conclusions, and recognize patient problems.
Data analysis
Information that can be observed, measured, or verified, such as blood pressure, temperature, or visible swelling.
Objective data
The thinking process used to interpret patient information, connect findings, consider possible explanations, and determine appropriate care.
Clinical reasoning
A systematic, ongoing approach to individualized care involving assessment, problem identification or nursing diagnosis, planning, implementation, and evaluation.
Nursing process
A clinical judgment about a person’s responses—or vulnerability to responses—to health conditions or life processes that guides nursing interventions.
Nursing diagnosis
Observable or measurable evidence of a health problem, such as a rash, fever, or elevated heart rate.
Signs
Interpretations or conclusions drawn from assessment information that may need further verification.
Inferences
A clinical judgment about a person’s responses—or vulnerability to responses—to health conditions or life processes that guides nursing interventions.
Nursing diagnosis
Carrying out the interventions in the nursing care plan and documenting the care provided and the patient’s response.
Implementation
The relative importance or urgency of a problem or action, which determines what should be addressed first.
Priority
Causes or contributing factors associated with a patient’s problem; often identified by the phrase “related to” in a nursing diagnosis.
Etiologic factors