Data that the patient gives that cannot be seen or felt by another, such as chest tightness.
What is subjective data?
100
The RN chooses problem statements or uses nursing diagnoses from this list.
What is NANDA-I?
100
MAR
What is Medication Administration Record?
100
This need must be met first according to Maslow's hierarchy of needs.
What is physiologic?
100
Purposeful, considered, organized cognitive processing used to examine a problem or situation.
What is critical thinking?
200
Information that is collected from other persons, such as a spouse, relative, or friend.
What are secondary sources?
200
Describes a specific result that should be met at a certain point in time. Written as "The patient will..."
What are expected outcomes?
200
EHR
What is Electronic Health Record?
200
This category includes a comfortable environment and psychological comfort.
What is Safety and Security?
200
A deliberate action performed to achieve a goal; carrying out of nursing interventions.
What is implementation?
300
This is done to prevent polypharmacy and involves collecting information about the patient's prescriptions, OTC meds, and herbal supplements they are currently taking.
What is medication reconciliation?
300
Nursing diagnoses are listed on the care plan in this order. Airway, for one.
What is priority?
300
Format used for nurses to communicate information pertaining to a patient.
What is SBAR?
300
This level of Maslow's needs includes independence, competence, and motivation.
What is Self-esteem?
300
Information obtained through the senses or measured by instruments.
What is objective data?
400
The patient's facial expressions, posture, and movements are the same as what the patient verbally states.
What is congruent?
400
Administering insulin to a diabetic person is an example of a nurse utilizing this type of core measure.
What is evidence-based practice?
400
HIPAA
What is the Health Insurance Portability and Accountability Act?
400
Affection, intimacy, and social interaction can be found in this level of Maslow's hierarchy of needs.
What is Love and Belonging?
400
A goal-directed series of activities in which the practice of nursing accomplishes its goal of alleviating, minimizing, or preventing real or potential health problems.
What is nursing process?
500
Part of the physical assessment that determines if a patient has pitting edema.
What is palpation?
500
Collecting information using this involves inspection, olfaction, palpation, auscultation, and percussion.
What is physical assessment?
500
This organization formulates and validates nursing diagnoses.
What is NANDA-I?
500
One must achieve reaching all other levels before they can have universal knowledge, openness, and achievement in this category of Maslow's needs.
What is Self-actualization?
500
This type of data collection is usually performed at the beginning of the shift, and is directed to areas in which the patient is experiencing health problems.