graded A+ updated
1. subjective data What patient says about himself or herself during
history taking
2. objective data Observed when inspecting, percussing, palpating,
and aus- cultating patient during physical
examination
3. Database formed from these elements, plus patient's record
and lab- oratory studies
4. Diagnostic reasoning a dynamic thinking process that leads to the
identification
of a hypothesis that best explains the clinical evidence
5. Steps of the Nursing Process 1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
6. Assessment - collect data from multiple sources
-use evidence-based assessment
-document relevant data
7. Steps of assessment collection 1. Review of clinical record
2. Interview
3. Health history
4. Physical examination
5. Functional assessment
6. Cultural and spiritual assessment
7. Consultation
8. Review of the literature
,NUR 230 Midterm Exam questions and answers
graded A+ updated
8. Nursing Process: Diagnosis
,NUR 230 Midterm Exam questions and answers
graded A+ updated
-Interpretation of data by identifying clusters of cues
so as to make inferences
-Compare clusters of cues with definitions and
defining characteristics
-Validation of inferences based on findings
-Identify related factors
-Document the diagnosis
9. Nursing Process: -identify expected outcomes related to individualization
Outcome Identification -ensure outcomes are realistic and measurable
-specify short-term and long-term goal
measurement cri- teria
10. Nursing Process: Planning - establish priorities
-develop outcomes
-set time frames for outcomes
-identify interventions
-utlize other health care members in planning process
-Document plan of care
11. Nursing Process: -Determine patient readiness and involve
Implementa- tion patient(s) in health care process
-Review planned interventions with interdisciplinary
health care team members to facilitate collaborative
ettort
-Utilize principles of delegation, being mindful of
supervi- sion and evaluation
-Counsel person and significant others
-Refer for continuing care
-Document care provided
,NUR 230 Midterm Exam questions and answers
graded A+ updated
12. Nursing Process: Evaluation - Refer to established outcomes
-Evaluate individual's condition and compare actual
out- comes with expected outcomes