Most reliable source of data, the patient
Type of intervention that are actions planned by the nurse that will help achieve patient goals/outcomes; should enhance patient outcomes and be based on judgement and knowledge
Clearly identify patient strengths and any actual and/or potential problems
Type of intervention carried out by physicians like a prescribed order
Develop a holistic plan of individualized care that specifies desired patient goals and related outcomes
Stage of planning best carried out by primary nurse or specialized nurse and assures continuum of care
Stage of planning that is developed by the nurse who performs the initial health history and physical assessment
Type of commitment that has a sense of "this is all I know", may experience burnout
Evaluation where you ask patient to demonstrate new skill
Type of intervention performed jointly by nurses and other members of the healthcare team
Includes physician orders, H&P, progress notes, diagnostic studies, lab reports, consultations, medical admission records, treatment records, etc.
Data from family or significant others
Type of nursing diagnosis that represents a diagnosis that patient is vulnerable to or at risk for ...
A person who does not meet a standard of health or has a limitation in an aspect of health status
Stage of planning carried out by any nurse and is adjusted an updated with patient responses to interventions to keep the plan current
Type of commitment that demonstrates satisfaction and pride, with positive experiences
Evaluation where you perform physical assessment to evaluate physical changes in the patient
Nursing outcomes should reflect standards of care without violating patient safety ; should be written in _______ terms, and be realistic and specific