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subjective sources of data - SOLUTION What the client tells the nurse
Objective sources of data - SOLUTION Data the nurse obtains through observation and examination
secondary subjective data - SOLUTION what others tell the nurse; what the client had told them
secondary objective sources of data - SOLUTION Data the nurse collects from other sources; family,
friends, caregivers, health care professionals, literature review, medical records, etc.
Steps of the Nursing Process - SOLUTION assessment/data collection, analysis/data collection, planning,
implementation, evaluation; ADPIE
Assessment/Data collection - SOLUTION the systemic collection of information about clients' present
health statuses to identify needs and additional data to collect based on findings
Analysis/data collection requires nurses to look at the data and: - SOLUTION recognize patterns or
trends; compare the data with expected standards or reference ranges, and arrive to conclusions to
guide nursing care
Planning - SOLUTION nurses must establish priorities and optimal outcomes of acre they can readily
measure and evaluate, which include interventions to promote, maintain, or restore health
Discharge planning - SOLUTION a process of anticipating and planning for client's needs after discharge.
To be effective, discharge planning must begin during admission
nurse-initiated/independent interventions - SOLUTION nurses use evidence and scientific rationale to
take autonomous actions to benefit clients; based on identified problems and health care needs, and
make sure they are within their scope of practice. An example is repositioning a client at least every 2
hours to prevent skin breakdown
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Provider-initiated/dependent interventions - SOLUTION interventions nurses initiate as a result of a
provider's prescription (written, standing, or verbal) or the facility's protocol (blood administration
procedures)
collaborative interventions - SOLUTION interventions nurses carry out in collaboration with other health
care team professionals (ensuring that a client receives and eats their evening snack)
Implementation - SOLUTION nurses base the care they provide based on assessment data, analysis, and
the plan of care they developed in the previous steps of the nursing process. In this step they must use
problem-solving, clinical judgement, and critical thinking to select and implement appropriate
therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to
promote, maintain, or restore health.
Evaluation - SOLUTION nurses evaluate clients' responses to nursing interventions and form a clinical
judgment about the extent to which clients have met the goals and outcomes; nurses determine the
effectiveness of the nursing care plan. They collect data based on the outcome criteria then compare
what actually happened with the planned outcomes; clients' outcomes in specific, measurable terms are
easier to evaluate
Evaluate: Questions to Consider - SOLUTION "Did the client meet the planned outcomes?", "were the
nursing interventions appropriate and effective?", "should I modify the outcomes or interventions?"
Factors that can lead to lack of goal achievement during evaluation - SOLUTION an incomplete database,
unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to
achieve the outcomes
4 steps of Critical Thinking - SOLUTION 1. identify and analyze the problem; 2. recall info you need to
resolve the problem; 3. evaluate each option; 4. select the correct or priority option
clients with diabetes mellitus should eat what when their blood glucose is low? - SOLUTION they should
eat a snack of 10-15 grams of carbohydrates, such as 120 mL or 4 oz of fruit juice
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subjective sources of data - SOLUTION What the client tells the nurse
Objective sources of data - SOLUTION Data the nurse obtains through observation and examination
secondary subjective data - SOLUTION what others tell the nurse; what the client had told them
secondary objective sources of data - SOLUTION Data the nurse collects from other sources; family,
friends, caregivers, health care professionals, literature review, medical records, etc.
Steps of the Nursing Process - SOLUTION assessment/data collection, analysis/data collection, planning,
implementation, evaluation; ADPIE
Assessment/Data collection - SOLUTION the systemic collection of information about clients' present
health statuses to identify needs and additional data to collect based on findings
Analysis/data collection requires nurses to look at the data and: - SOLUTION recognize patterns or
trends; compare the data with expected standards or reference ranges, and arrive to conclusions to
guide nursing care
Planning - SOLUTION nurses must establish priorities and optimal outcomes of acre they can readily
measure and evaluate, which include interventions to promote, maintain, or restore health
Discharge planning - SOLUTION a process of anticipating and planning for client's needs after discharge.
To be effective, discharge planning must begin during admission
nurse-initiated/independent interventions - SOLUTION nurses use evidence and scientific rationale to
take autonomous actions to benefit clients; based on identified problems and health care needs, and
make sure they are within their scope of practice. An example is repositioning a client at least every 2
hours to prevent skin breakdown
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Provider-initiated/dependent interventions - SOLUTION interventions nurses initiate as a result of a
provider's prescription (written, standing, or verbal) or the facility's protocol (blood administration
procedures)
collaborative interventions - SOLUTION interventions nurses carry out in collaboration with other health
care team professionals (ensuring that a client receives and eats their evening snack)
Implementation - SOLUTION nurses base the care they provide based on assessment data, analysis, and
the plan of care they developed in the previous steps of the nursing process. In this step they must use
problem-solving, clinical judgement, and critical thinking to select and implement appropriate
therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to
promote, maintain, or restore health.
Evaluation - SOLUTION nurses evaluate clients' responses to nursing interventions and form a clinical
judgment about the extent to which clients have met the goals and outcomes; nurses determine the
effectiveness of the nursing care plan. They collect data based on the outcome criteria then compare
what actually happened with the planned outcomes; clients' outcomes in specific, measurable terms are
easier to evaluate
Evaluate: Questions to Consider - SOLUTION "Did the client meet the planned outcomes?", "were the
nursing interventions appropriate and effective?", "should I modify the outcomes or interventions?"
Factors that can lead to lack of goal achievement during evaluation - SOLUTION an incomplete database,
unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to
achieve the outcomes
4 steps of Critical Thinking - SOLUTION 1. identify and analyze the problem; 2. recall info you need to
resolve the problem; 3. evaluate each option; 4. select the correct or priority option
clients with diabetes mellitus should eat what when their blood glucose is low? - SOLUTION they should
eat a snack of 10-15 grams of carbohydrates, such as 120 mL or 4 oz of fruit juice
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