It is the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping problems.
What is assessment?
100
The D in ADPIE stands for this. It is a clinical judgment about the patient in response to an actual or potential health problem.
What is nursing diagnosis?
100
The goal, "Patient will be able to self-administer insulin." demonstrates this characteristic.
What is observable?
100
It is any treatment based on clinical judgment an knowledge that a nurse performs to enhance patient outcomes. It is the I in ADPIE.
What is a nursing intervention/implementation?
100
This is an ongoing process. This is the E in ADPIE.
What is evaluation?
200
Information obtained through use of the senses.
What is a cue?
200
The PES format stands for this.
What is Problem, Etiology, and Symptoms?
200
Physician-initiated interventions that require an order from a physician or another health care professional.
What are dependent nursing interventions?
200
Interventions that are treatment performed through interactions with patients.
What is direct care?
200
The minimum level of care accepted to ensure high quality of care to patients.
What is standard of care?
300
Judgment or interpretation of information obtained though the use of the senses.
What is an inference?
300
It describes human response to health conditions/life processes that may develop.
What is risk nursing diagnosis?
300
An objective behavior or response expected within hours to a week.
What is short-term goal?
300
These are implementation skills that involve the application of critical thinking in the nursing process. Always use good judgment and sound clinical decision making when performing any intervention.
What are cognitive skills?
300
Psychological, emotional, and behavioral responses that are a patient's goals and expected outcomes.
What are criterion-based standards?
400
Type of data obtained through patients' verbal descriptions of their health problems. (Symptoms)
What is subjective data?
400
It is a condition, historical factor, or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.
What is Etiology or related factor?
400
It is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions.
What is priority setting?
400
These are to be used as evidence of the standard of care that registered nurses provide their patients.
What are ANA Standards of Professional Nursing Practice?
400
End result that is measurable, desirable, and observable, and translates into observable patient behaviors
What is expected outcome?
500
Is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness.
What is patient-centered interview?
500
It is a set of signs or symptoms gathered during assessment that are grouped together in a logical way.
What is data cluster?
500
A specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function.
What is patient-centered goal?
500
It is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.
What is a standing order?
500
A goal specifies the expected behavior or response that indicates:
a. The specific nursing action was completed.
b. The validation of the nurse's physical assessment.
c. The nurse has made the correct nursing diagnoses.
d. Resolution of a nursing diagnosis or maintenance of a healthy state.