Assessment
Diagnosis
Goals/Outcomes
Interventions
Evaluations
100
"I am in such pain" "I dont' know anything about breastfeeding" "I am afraid I am going to die"
What are examples of Subjective Data
100
Actual diagnosis Potential diagnosis Health Promotion diagnosis
What are the three types of nursing diagnoses
100
Priority Setting
What is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions?
100
NIC
What is Nursing Interventions Classifications? Standard nursing interventions that have been shown to be effective.
100
Evaluation is an ongoing process. The evaluation may or may not show positive results Evaluation may result in a change in the care plan
What are all true statements about the evaluation process?
200
sleep-rest patterns health perception value-belief pattern
What are examples of Function Health Patterns?
200
NANDA-I
What is the North American Nursing Diagnosis Association-International
200
A specific measureable change in a patient's status that you expect to occur in response to nursing care.
What is an expected outcome?
200
Performing a dressing change Teaching a client how to draw up insulin Answering questions regarding an upcoming procedure for the client Arranging for home care nursing and therapy after discharge Finding AA meeting locations for client
What are examples of direct and indirect nursing interventions?
200
Measure size of a wound. Ask client to list S&S of a wound infection. Have client walk. Have spouse show you how to attach IV infusion.
What are ways to evaluate if goals/outcomes have been met?
300
Lab values History and physical by MD Old chart Head to toe assessment
What are examples of Objective Data?
300
Diagnosis Related to As Evidenced By
What are the three components of a complete actual nursing diagnosis.
300
Measurable Realistic Time-Limited Observable Mutual Single
What are the criteria for a goal/outcome?
300
Providing client with tube feedings via a gastrostomy tube of Pulmocare full strength, 100cc /hr. Provide 150 cc free water every 8 hrs via G-tube. Perform wound care as follows: Cleanse wound with NS, apply calcium alginate, cover with CDD. Perform every 3 days.
What are examples of a physician initiated intervention?
300
Client did not agree to the goal Wrong diagnosis was selected by nurse Goal was not measurable
What are reasons why goals/outcomes are not met?
400
Confirming with family that client is taking meds as ordered. Having client perform a dressing change in front of you. Reviewing an old chart for date of last EKG
What is validating data?
400
Grieving Impaired Physical Mobility Ineffective Airway Clearance
What are all NANDA diagnoses?
400
Client will ambulate 50 feet with walker daily by the end of week 1. Client will be independent with ambulation up to 100 feet by Christmas vacation.
What are examples of short and long term goals?
400
Repositioning a client every 2 hrs to prevent skin breakdown. Listening to a client express fears of dying. Writing down steps for oral suctioning for a client and his family
What are examples of nursing initiated interventions?
400
Therapist Floor Nurse Social Worker Clinical Educator
What are examples of people who can help evaluate?
500
The last part of a nursing assessment
What is documentation?
500
Assessment Highlight Relevant Symptoms List Symptoms Cluster similiar Symptoms Analyze/ Interpret
What are the steps need to complete before you can make a diagnosis?
500
NOC
What is Nursing Outcomes Classification? A common set of outcomes
500
Taking vital signs Ambulating a patient Helping a client bathe Check if a client is sleeping
What are examples of interventions that can be delegated by the nurse.
500
Documentation of goals met or unmet.
What is the final aspect of the evaluation step?
M
e
n
u