NUR 101: Nursing Process
Assess - ANS-Step 1 of Nursing process: gather information about pt condition
Diagnose - ANS-Step 2 of Nursing Process: Identify Pt. problems
Plan - ANS-Step 3 of Nursing Process
Assessment - ANS-Deliberate and systematic collection of information about a patient to
determine the patient's current and past health and functional status, and present and past
coping patterns
Comprehensive Assessment - ANS-overall
Focused Assessment - ANS-Problem oriented
Subjective Data - ANS-patient's verbal descriptions of their health problems
Objective Data - ANS-(Pain is considered objective) observations or measurements of a
patient's health status.
Sources of Data - ANS-Best source is from patient. Others are family, healthcare team, medical
records, military records, employment records, educational records, (these records are mostly
for immunizations) nurse's experience
Interview (source of data collection) - ANS-Obtain history and procedure, identify health needs
and risk factors
determine change in level of wellness
allow pt to voice interpretation and understanding of their condition
Health History (source of data collection) - ANS-Physical and developmental, intellectual,
spiritual, social, emotional
Physical Exam (source of data collection) - ANS-Head to toe, measurements, objective and
observable
Diagnostic and Laboratory Data - ANS-Requires a dr. order, review results, verify abnormals,
provides baseline, directs other data collection, confirms problem, resolution of problem
Data Cluster - ANS-Set of cues, signs, or symptoms gathered during an assessment. intentional
assessment and unintentional assessment. Cues can be subjective or objective
Assess - ANS-Step 1 of Nursing process: gather information about pt condition
Diagnose - ANS-Step 2 of Nursing Process: Identify Pt. problems
Plan - ANS-Step 3 of Nursing Process
Assessment - ANS-Deliberate and systematic collection of information about a patient to
determine the patient's current and past health and functional status, and present and past
coping patterns
Comprehensive Assessment - ANS-overall
Focused Assessment - ANS-Problem oriented
Subjective Data - ANS-patient's verbal descriptions of their health problems
Objective Data - ANS-(Pain is considered objective) observations or measurements of a
patient's health status.
Sources of Data - ANS-Best source is from patient. Others are family, healthcare team, medical
records, military records, employment records, educational records, (these records are mostly
for immunizations) nurse's experience
Interview (source of data collection) - ANS-Obtain history and procedure, identify health needs
and risk factors
determine change in level of wellness
allow pt to voice interpretation and understanding of their condition
Health History (source of data collection) - ANS-Physical and developmental, intellectual,
spiritual, social, emotional
Physical Exam (source of data collection) - ANS-Head to toe, measurements, objective and
observable
Diagnostic and Laboratory Data - ANS-Requires a dr. order, review results, verify abnormals,
provides baseline, directs other data collection, confirms problem, resolution of problem
Data Cluster - ANS-Set of cues, signs, or symptoms gathered during an assessment. intentional
assessment and unintentional assessment. Cues can be subjective or objective
