NURS 3206 FOUNDATIONS – EXAM 1 CHEAT SHEET
Nursing Process- Steps and Order of the Nursing Process
1. Assessment
Assessment involves gathering comprehensive information about a patient, family, or
community, organizing the data, identifying patterns, and making clinical judgments to
determine the patient’s health problems.
• Assessment relies on clinical judgment and is influenced by the patient’s current
response and the urgency of their condition; it is situation-specific.
• It includes collecting data from:
o Primary sources (the patient)
o Secondary sources (family, caregivers, medical records, friends)
• The nurse interprets, verifies, and validates all collected data.
• Assessment is dynamic and changes as the patient’s condition changes.
Types of Assessment:
• Patient-centered interview: Includes physical, psychological, spiritual, and lifestyle
information.
• Periodic assessment: Quick reassessments during routine rounding.
o Uses ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure)
to rapidly identify priority issues and evaluate physiological stability.
• Physical examination: Systematic review of body systems with focus on problem areas
to confirm findings.
o Includes pain characteristics such as onset, location, severity, radiation, and
contributing factors.
o Used to validate clinical observations and findings.
2. Analysis and Diagnosis
This step involves interpreting collected data to identify the patient’s health problems.
• Data is grouped into clusters of related signs and symptoms to form clinical patterns.
• The nurse determines appropriate nursing diagnoses based on these patterns.
3. Planning
Planning involves establishing patient-centered goals, expected outcomes, and selecting
appropriate nursing interventions.
• Goals and outcomes are prioritized after identifying nursing diagnoses.
• A individualized plan of care is developed to support achievement of outcomes.
• Includes:
o Prioritizing nursing diagnoses
o Establishing measurable patient goals
o Developing tailored nursing interventions
• Discharge planning begins at admission and continues throughout hospitalization.
4. Implementation
Implementation is the execution of planned nursing interventions.
• Interventions must be supported by evidence-based rationale.
Types of Nursing Care:
• Direct care: Care delivered through direct interaction with the patient.
, o Examples include assisting with activities of daily living (ADLs),
medication administration, education, catheter insertion, counseling, and
discharge teaching.
• Indirect care: Interventions performed away from the patient but on their behalf.
o Includes documentation, care coordination, communication during hand-
offs, and interprofessional collaboration.
5. Evaluation
Evaluation determines whether patient outcomes have been achieved.
• The nurse decides whether to continue, modify, or discontinue the care plan based on
patient progress.
Subjective vs Objective Data
• Subjective data: Information provided directly by the patient during interviews,
including feelings, symptoms, and perceptions.
o Only the patient can report this type of data.
o Reflects physical, psychological, or social experiences.
• Objective data: Observable and measurable information gathered through assessment.
o Includes vital signs, physical appearance, behavior, gait, wound condition, and
measurable clinical findings.
Nursing Diagnosis vs Medical Diagnosis
Nursing Diagnosis:
A nursing diagnosis is a clinical judgment about how an individual, family, or community
responds to actual or potential health conditions that nurses are licensed to manage.
Types of Nursing Diagnoses:
• Problem-focused (actual): Current health issue supported by defining
characteristics.
o Format: Problem related to cause as evidenced by symptoms
o Example: Anxiety related to situational stress as evidenced by restlessness and
insomnia.
• Risk diagnosis: Identifies vulnerability to developing a problem.
o Format: Risk for ___ as evidenced by risk factors
o Example: Risk for infection as evidenced by immunosuppression.
• Health promotion: Focuses on readiness to improve health status.
o Format: Readiness for ___ as evidenced by desire to improve
o Example: Readiness for enhanced self-care as evidenced by expressed
motivation.
Medical Diagnosis
A medical diagnosis identifies a disease or condition based on physical examination, history, and
diagnostic testing.
• Example: Pneumonia
• Nursing response example: Ineffective airway clearance
Prioritization of Care
Prioritization is guided first by immediate physiological needs and then by Maslow’s Hierarchy
of Needs.
, 1. Physiological needs (highest priority): Airway, breathing, circulation, nutrition,
elimination, sleep, temperature, fluid balance, pain, infection, and skin integrity.
2. Safety and security: Injury prevention and safe environment.
3. Love and belonging: Relationships and communication.
4. Self-esteem: Confidence, independence, and achievement.
5. Self-actualization: Personal growth, spirituality, and fulfillment.
ABC Rule: Airway, Breathing, and Circulation always take priority, followed by pain and acute
concerns.
SMART Outcome Statements
• Specific: Focus on one clear patient behavior or outcome at a time.
• Measurable: Must be observable or quantifiable using clear indicators (vital signs,
scales, frequency).
• Attainable: Realistic and agreed upon by both nurse and patient.
• Realistic: Appropriate for the patient’s condition, abilities, and available resources.
• Timed: Includes a clear deadline for achievement.
Nursing Interventions
Dependent Interventions
Require a provider order.
• Examples: medication administration, IV therapy, oxygen therapy, diagnostic
preparation, catheter insertion.
Independent Interventions
Initiated by the nurse without a provider order, based on clinical judgment.
• Examples: patient repositioning, education, stress management teaching, early mobility,
coping support.
Interdependent (Collaborative) Interventions
Require teamwork among multiple healthcare professionals.
• Example: collaboration with physical therapy, pharmacy, or social work.
Evaluation Process
Evaluation is continuous and involves comparing patient outcomes before and after
interventions.
• Data is collected from patients, families, and the healthcare team.
• The nurse determines if outcomes are met, partially met, or unmet.
• Decisions are made to continue, modify, or discontinue care.
• Care plans must be evaluated regularly, often every shift, to ensure safe care.
Delegation to Nursing Assistive Personnel (NAP)
• Nurses may delegate tasks but not the nursing process or clinical judgment.
• Appropriate delegated tasks include basic, noninvasive, and routine care for stable
patients (hygiene, mobility, vital signs).
• The nurse remains accountable for delegated tasks.
• Delegation must include clear instructions, expectations, and ongoing communication.
5 Rights of Delegation:
1. Right task
Nursing Process- Steps and Order of the Nursing Process
1. Assessment
Assessment involves gathering comprehensive information about a patient, family, or
community, organizing the data, identifying patterns, and making clinical judgments to
determine the patient’s health problems.
• Assessment relies on clinical judgment and is influenced by the patient’s current
response and the urgency of their condition; it is situation-specific.
• It includes collecting data from:
o Primary sources (the patient)
o Secondary sources (family, caregivers, medical records, friends)
• The nurse interprets, verifies, and validates all collected data.
• Assessment is dynamic and changes as the patient’s condition changes.
Types of Assessment:
• Patient-centered interview: Includes physical, psychological, spiritual, and lifestyle
information.
• Periodic assessment: Quick reassessments during routine rounding.
o Uses ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure)
to rapidly identify priority issues and evaluate physiological stability.
• Physical examination: Systematic review of body systems with focus on problem areas
to confirm findings.
o Includes pain characteristics such as onset, location, severity, radiation, and
contributing factors.
o Used to validate clinical observations and findings.
2. Analysis and Diagnosis
This step involves interpreting collected data to identify the patient’s health problems.
• Data is grouped into clusters of related signs and symptoms to form clinical patterns.
• The nurse determines appropriate nursing diagnoses based on these patterns.
3. Planning
Planning involves establishing patient-centered goals, expected outcomes, and selecting
appropriate nursing interventions.
• Goals and outcomes are prioritized after identifying nursing diagnoses.
• A individualized plan of care is developed to support achievement of outcomes.
• Includes:
o Prioritizing nursing diagnoses
o Establishing measurable patient goals
o Developing tailored nursing interventions
• Discharge planning begins at admission and continues throughout hospitalization.
4. Implementation
Implementation is the execution of planned nursing interventions.
• Interventions must be supported by evidence-based rationale.
Types of Nursing Care:
• Direct care: Care delivered through direct interaction with the patient.
, o Examples include assisting with activities of daily living (ADLs),
medication administration, education, catheter insertion, counseling, and
discharge teaching.
• Indirect care: Interventions performed away from the patient but on their behalf.
o Includes documentation, care coordination, communication during hand-
offs, and interprofessional collaboration.
5. Evaluation
Evaluation determines whether patient outcomes have been achieved.
• The nurse decides whether to continue, modify, or discontinue the care plan based on
patient progress.
Subjective vs Objective Data
• Subjective data: Information provided directly by the patient during interviews,
including feelings, symptoms, and perceptions.
o Only the patient can report this type of data.
o Reflects physical, psychological, or social experiences.
• Objective data: Observable and measurable information gathered through assessment.
o Includes vital signs, physical appearance, behavior, gait, wound condition, and
measurable clinical findings.
Nursing Diagnosis vs Medical Diagnosis
Nursing Diagnosis:
A nursing diagnosis is a clinical judgment about how an individual, family, or community
responds to actual or potential health conditions that nurses are licensed to manage.
Types of Nursing Diagnoses:
• Problem-focused (actual): Current health issue supported by defining
characteristics.
o Format: Problem related to cause as evidenced by symptoms
o Example: Anxiety related to situational stress as evidenced by restlessness and
insomnia.
• Risk diagnosis: Identifies vulnerability to developing a problem.
o Format: Risk for ___ as evidenced by risk factors
o Example: Risk for infection as evidenced by immunosuppression.
• Health promotion: Focuses on readiness to improve health status.
o Format: Readiness for ___ as evidenced by desire to improve
o Example: Readiness for enhanced self-care as evidenced by expressed
motivation.
Medical Diagnosis
A medical diagnosis identifies a disease or condition based on physical examination, history, and
diagnostic testing.
• Example: Pneumonia
• Nursing response example: Ineffective airway clearance
Prioritization of Care
Prioritization is guided first by immediate physiological needs and then by Maslow’s Hierarchy
of Needs.
, 1. Physiological needs (highest priority): Airway, breathing, circulation, nutrition,
elimination, sleep, temperature, fluid balance, pain, infection, and skin integrity.
2. Safety and security: Injury prevention and safe environment.
3. Love and belonging: Relationships and communication.
4. Self-esteem: Confidence, independence, and achievement.
5. Self-actualization: Personal growth, spirituality, and fulfillment.
ABC Rule: Airway, Breathing, and Circulation always take priority, followed by pain and acute
concerns.
SMART Outcome Statements
• Specific: Focus on one clear patient behavior or outcome at a time.
• Measurable: Must be observable or quantifiable using clear indicators (vital signs,
scales, frequency).
• Attainable: Realistic and agreed upon by both nurse and patient.
• Realistic: Appropriate for the patient’s condition, abilities, and available resources.
• Timed: Includes a clear deadline for achievement.
Nursing Interventions
Dependent Interventions
Require a provider order.
• Examples: medication administration, IV therapy, oxygen therapy, diagnostic
preparation, catheter insertion.
Independent Interventions
Initiated by the nurse without a provider order, based on clinical judgment.
• Examples: patient repositioning, education, stress management teaching, early mobility,
coping support.
Interdependent (Collaborative) Interventions
Require teamwork among multiple healthcare professionals.
• Example: collaboration with physical therapy, pharmacy, or social work.
Evaluation Process
Evaluation is continuous and involves comparing patient outcomes before and after
interventions.
• Data is collected from patients, families, and the healthcare team.
• The nurse determines if outcomes are met, partially met, or unmet.
• Decisions are made to continue, modify, or discontinue care.
• Care plans must be evaluated regularly, often every shift, to ensure safe care.
Delegation to Nursing Assistive Personnel (NAP)
• Nurses may delegate tasks but not the nursing process or clinical judgment.
• Appropriate delegated tasks include basic, noninvasive, and routine care for stable
patients (hygiene, mobility, vital signs).
• The nurse remains accountable for delegated tasks.
• Delegation must include clear instructions, expectations, and ongoing communication.
5 Rights of Delegation:
1. Right task
