Medical diagnosis—A medical determination of disease or syndrome performed by a physician. The focus is on the disease process and the physical, genetic, or environmental cause of that process.
NIC, Nursing Interventions Classification— Developed by the Iowa Intervention Project, this is a collection of nursing interventions linked to the NANDA diagnoses. The 2000 publication includes approximately 500 interventions.NOC, Nursing Outcomes Classification— Developed by the Iowa Outcome Project, this is a comprehensive, standardized classification of patient outcomes developed to evaluate the effects of nursing interventions. The outcomes may be linked to the NANDA diagnoses and other diagnoses systems. The 2000 publication includes 260 outcomes.
Nursing assessment—The way in which a nurse gathers and evaluates data about a client (individual, family, or community). The assessment includes a physical examination, interviewing, and observations. Assessment is also the first step in the nursing process.
Nursing diagnostic statement—The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by."
Nursing intervention—Any treatment that a nurse performs on a patient in response to a nursing diagnosis to reach a projected outcome.
Risk diagnosis—A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment.
