Assessment
This type of data is reported by the patient and cannot be measured directly
What is subjective data?
A diagnosis that exists currently and is supported by patient data.
What is actual nursing diagnosis?
S in SMART goals stands for…
Specific
Actions nurses can perform without a doctor’s order.
What is he Independent interventions?
Patient meets goal as planned.
Achieved expected outcome
Temperature 38°C and BP 140/90 mmHg are examples of what type of data?
objective data
A diagnosis that may occur if risk factors are present, but there is no current problem
What is potential/risk nursing diagnosis?
T in SMART goals stands for…
Time-bound
Actions done with other healthcare professionals
What is the Collaborative interventions?
Patient shows some improvement, goal not fully met
Progressing toward outcome
Patient reports nausea and dizziness, vitals normal. Identify subjective vs. objective data.
Subjective: nausea, dizziness; Objective: vitals normal
Patient reports pain 8/10 at incision, wound slightly red. Identify actual or potential diagnosis.
Actual: Acute pain related to incision
Pain ≤3/10 within 2 hours. Identify S, M, A, R, T.
S: pain reduction; M: 7→3; A: achievable; R: post-op relevance; T: 2 hours
Teach deep breathing and coordinate with physiotherapy. Identify intervention types
Independent: teach breathing; Collaborative: physiotherapy
Patient progress slower than expected; interventions adjusted
Plan modified / outcome partially met
You notice a surgical wound that is red and draining pus, but the patient reports no pain. Which is subjective, which is objective, and what does it indicate?
Subjective: none; Objective: wound appearance; indicates potential complication
Patient post-op, weak, not ambulating yet. Identify risk diagnosis.
Risk for falls related to immobility
Write a SMART goal for a patient at risk of infection.
Patient’s incision remains free of redness, swelling, or drainage during hospital stay.
Patient has Ineffective Airway Clearance related to retained secretions. Name one independent, one collaborative
Independent: teach coughing/deep breathing; Collaborative: coordinate with respiratory therapy
Patient shows no improvement; interventions ineffective.
Not progressing / goal not met
Patient SOB after ambulation; O₂ 94%, HR 95. Document for NCP?
Subjective: SOB; Objective: O₂ 94%, HR 95; Context: after walking
Patient weak after surgery, has limited mobility. Identify actual or potential diagnosis.
Potential: Risk for falls related to weakness
Patient reports anxiety pre-surgery. Write a SMART goal.
Patient will report anxiety ≤3/10 by end of pre-op teaching session.
Teaching a diabetic patient to monitor blood sugar and giving vaccines to prevent illness. What type of interventions?
Educational / Preventive interventions
Patient pain remains 6/10 after interventions; wound slightly inflamed. How do you categorize outcome and next step?
Not progressing; escalate to physician, revise plan, document changes