FINAL EXAM (HEALTH
ASSESSMENT)
1. Subjective and Objective data
Answer Subjective data
-the information the patient tells the nurse
-includes the patients perception of their health status, level of pain, history of health and illness, list of allergies, recall
of food eaten, and medications being taken.
-gathers it through the interview
-data collected comes from
1. Primary source = the patient.
2. Secondary sources = family members or caregivers
,Objective data
-the information the nurse measures or observes on the patient.
-measurable
-may be found in charts and be relevant to growth and development or in laboratory values.
-components of the physical assessment include the general survey and examination of body systems
Page 31 ATI
2. Nursing process
Answer ADPIE
1. Assessment
-gather information about patient`s condition
-collecting information from the patient (primary source) and from secondary sources, along with interpreting and
validating the information to form a complete database.
-information/data can be subjective or objective
,-subjective data can come from primary/secondary source
-nurse can collect data during initial assessment, focused assessment, and ongoing assessment
-2 stages
>Collection and verification of data
>Analysis of data
2. Diagnosis
-identify the patient`s problem
-Subjective and objective data are compared with normative expected values and standards.
-Nursing diagnoses are relevant to patient problems and will be the focus of nursing care to reach a goal or outcome
, that is determined during the planning phase of the nursing process.
3. Planning
-set goals of care and desired outcomes
-establish priorities and optimal outcomes of care
-identify appropriate nursing actions
-goals should be SMART
(specific, measurable, attainable, relevant, time)
4. Implementation
-perform the nursing actions identified in planning
-the nurse carries out specific, relevant nursing interventions meant to achieve the goals set in the planning phase
5. Evaluation
ASSESSMENT)
1. Subjective and Objective data
Answer Subjective data
-the information the patient tells the nurse
-includes the patients perception of their health status, level of pain, history of health and illness, list of allergies, recall
of food eaten, and medications being taken.
-gathers it through the interview
-data collected comes from
1. Primary source = the patient.
2. Secondary sources = family members or caregivers
,Objective data
-the information the nurse measures or observes on the patient.
-measurable
-may be found in charts and be relevant to growth and development or in laboratory values.
-components of the physical assessment include the general survey and examination of body systems
Page 31 ATI
2. Nursing process
Answer ADPIE
1. Assessment
-gather information about patient`s condition
-collecting information from the patient (primary source) and from secondary sources, along with interpreting and
validating the information to form a complete database.
-information/data can be subjective or objective
,-subjective data can come from primary/secondary source
-nurse can collect data during initial assessment, focused assessment, and ongoing assessment
-2 stages
>Collection and verification of data
>Analysis of data
2. Diagnosis
-identify the patient`s problem
-Subjective and objective data are compared with normative expected values and standards.
-Nursing diagnoses are relevant to patient problems and will be the focus of nursing care to reach a goal or outcome
, that is determined during the planning phase of the nursing process.
3. Planning
-set goals of care and desired outcomes
-establish priorities and optimal outcomes of care
-identify appropriate nursing actions
-goals should be SMART
(specific, measurable, attainable, relevant, time)
4. Implementation
-perform the nursing actions identified in planning
-the nurse carries out specific, relevant nursing interventions meant to achieve the goals set in the planning phase
5. Evaluation
