This person should be the primary source of your information gathering
What is the patient
100
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
100
To promote optimum or an improved level of functioning for the patient
What is The Ultimate Goal of the Planning Phase
100
Nursing implementation begins with this step
What is Identifying the Priority Intervention
100
These are the degrees of goal attainment
What is Met, Partially Met, or Not Met
200
Symptoms are this type of data
What is subjective
200
The problem statement of an actual diagnosis consists of these 3 things
What is Problem, Etiology, and Defining Characteristics
200
Meeting a patient's basic physiological needs before higher level needs of a safe environment, security, love and belonging, and so on, follows this nursing theory
What is Maslow's Hierarchy of Needs
200
This type of charting refers to a traditional, sequential, documentation system
What is Narrative Charting
200
Evaluation involves this action, beginning with initial data collection and continuing through implementation
What is Critical Analysis
300
Signs are this type of data
What is objective
300
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
300
These terms are often used interchangeably with Goal
What is Outcome and Expected Outcome
300
The nurse has a legal and ethical responsibility to protect a patient's information. We call this _______
What is Confidentiality, Privacy, Privileged
300
Both of these descriptors may indicate that a change might be made to the care plan
What is Progress and Lack of Progress
400
These are the three methods of data collection
What is observation, interview, and physical assessment
400
When documenting the etiology of a problem you might use this phrase
What is Related To (R/T)
400
These classifications are 1) a method for linking nursing interventions to diagnoses and client outcomes. And 2) describes an outcome as a measurable individual, family or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions
What is NIC and NOC
400
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
400
This action should be performed prior to a hospital patient's discharge.
What is Evaluation and Writing an Evaluative Statement
500
This term means that all aspects of the patient's physical, emotional, social, spiritual, and economic well-being are considered
What is Holistic
500
This may require different nursing interventions
What is cause or etiology
500
These are specified activities executed by the nursing team that benefit the client in a predictable manner
What is Nursing Interventions
500
This is a condensed reference tool that includes basic client care information. It is not a part of the permanent chart
What is the Kardex
500
These 3 essential cognitive skills are practiced in all steps of the nursing process
What is Critical Thinking, Decision Making, Problem Solving