signs - answerobjective data observed, felt, heard or measured.
ex: rash, enlarged lymph nodes, swelling
symptoms - answersubjective data perceived and reported by the patient
ex: pain, itching and nausea
clinical manifestation - answerdescribe the presenting signs and symptoms experienced
by a patient
medical diagnosis - answerfocuses on pathology; concept that defines a disease
process or injury
- describes human responses to potential or actual health problems
nursing diagnosis - answerdescribes human responses to potential or actual health
problems
- begins by clustering data from patient's story (temp and blood pressure)
ADPIE - answerAssess
diagnose
plan
implement care
evaluate
assessment - answerbiophysical, psychological, sociocultural, spiritual and
environmental characteristics
problem - answerthe nursing diagnosis label: a concise term or phrase that represents a
pattern of related cues
Etiology - answer"related to" (r/t) phrase: related to cause or contributor to the problem
PES - answerproblem
etiology
symptoms
Problem focused/ actual - answer-etiologies
-circumstances
-facts or influences that have some type of relationship with the nursing diagnosis
(have symptoms)
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