Assessment
This type of data includes what the patient says, such as “I feel nauseous.”
Subjective Data
This is the type of diagnosis that you give a patient when creating a care plan.
What is a NANDA diagnosis?
First step in the planning process.
What is determining goals for the patient?
This is done continuously after implementation of an intervention.
What is monitoring and adjusting interventions?
What is the step of the Clinical Judgement Measurement Model that correlates with evaluation?
What is "evaluate outcomes"?
Counting respirations, measuring blood pressure, and observing a wound are examples of this kind of data.
Objective Data
These are the steps in the Clinical Judgement Measurement Model that correlates with diagnosis.
What is analyze cues and prioritize hypothesis?
Repositioning a patient every 2 hours is an example of this.
What is a nurse-initiated intervention?
Before carrying out any intervention, the nurse should always check these two things.
What are the provider’s orders and the patient’s safety/status?
This is the main question you ask yourself during the evaluation phase.
Is the plan/intervention effective?
Gathering information from family members, medical records, or other healthcare providers provides what type of data?
Secondary Data
True or False: A nursing diagnosis can be written directly from a medical diagnosis.
What is false?
This process begins at admission
What is a plan for discharge?
You must document this when implementing your interventions.
What is the patient response to the intervention?
For the last part of the nursing process, you document ____ or this _____.
What is goal met or not met?
interview, observation, discussion with client and family, medical history, labs/diagnostics, and focused-physical assessmen
What are methods of data collection?
Step 1 of deciding on a nursing diagnosis for a patient.
What is analyzing and interpreting data to determine client’s biggest need/concern?
These are patient-centered and determined during the planning phase of the nursing process.
What are interventions?
True or False. The RN may delegate interventions to a UAP.
What is true?
This what I should do if a realize that my goal for the patient is to walk 10 yards, but they are unable to take 5 steps.
What is adjusting the interventions and modifying the goals?
This is the first step on the Clinical Judgement Measurement Model that correlates with assessment.
What is "recognize cues"?
The three-part structure of a nursing diagnosis includes these components.
What are problem, related-to (etiology), and as evidenced by?
These are two things that a goal must be...
What is achievable and measureable?
What is the step of the Clinical Judgement Measurement Model that correlates with implementation?
What is "take action"?
This is what you should do with each care plan that you complete as a nurse.
What is learn from the care plan and improve critical thinking skills?