Assessment
This person should be the primary source of your information gathering
What is the patient?
This type of nursing diagnosis describes the patient's response to a physical, sociocultural, psychological, or spiritual illness, disease, or condition. Actual signs and symptoms are present
What is Actual Nursing Diagnosis?
Completed by all nurses who work with the client
What is ongoing planning?
Nursing implementation begins with this step
What is Identifying the Priority Intervention?
These are the degrees of goal attainment
What is Met, Partially Met, or Not Met?
Symptoms are this type of data
What is subjective?
The problem statement of an actual diagnosis consists of these 3 things
What is Problem, Etiology, and Defining Characteristics?
Transfer of responsibility for the performance of an
activity to another person while retaining accountability for the outcome
What is delegation?
Evaluation involves this action, beginning with initial data collection and continuing through implementation
What is Critical Analysis
Signs are this type of data
What is objective?
A medical diagnosis stays the same throughout a patient's stay, a nursing diagnosis can do this
What is change as the patient's responses change?
These terms are often used interchangeably with Goal
What is Outcome and Expected Outcome
The nurse has a legal and ethical responsibility to protect a patient's information. We call this _______
What is confidentiality or privacy?
Both of these descriptors may indicate that a change might be made to the care plan
What is Progress and Lack of Progress
These are the three methods of data collection
What are observation, interview, and physical assessment?
When documenting the etiology of a problem you might use this phrase
What is Related To (R/T)?
The type of planning initiated with the admissions assessment
What is initial planning?
We describe this as a teamwork approach to patient care. All pertinent healthcare providers are included in the care and planning of care for the patient
What is Interdisciplinary Collaboration?
This action should be performed prior to a hospital patient's discharge.
What is Evaluation and Writing an Evaluative Statement
An important part of assessment that communicates findings to others
What is documentation?
These diagnoses are written in two-part statements
What are risk diagnoses and health promotion diagnoses?
The process of anticipating and planning for needs after discharge.
What is discharge planning?
These are specified activities executed by the nursing team that benefit the client in a predictable manner
What are nursing interventions?
These 3 essential cognitive skills are practiced in all steps of the nursing process
What is Critical Thinking, Decision Making, Problem Solving