Chapter 1B Flashcards
Developing a plan of nursing care and outcome criteria
A. Nursing assessment
B. Planning
C. Nursing diagnostic phase
D. Collaborative problem
B. Planning
Analysis of subjective & objective data to make a professional nursing judgment
A. Implementation
B. Nursing diagnostic phase
C. Evaluation
B. Nursing diagnostic phase
Collection of subjective & objective data
A. Planning
B. Evaluation
C. Nursing assessment
D. Nursing diagnosis
C. Nursing assessment
Sensations or symptoms that can be verified only by the client (e.g., pain)
A. Subjective data
B. Objective data
A. Subjective data
Carrying out the plan of care
A. Planning
B. Nursing assessment
C. Implementation
C. Implementation
Problem that requires the attention or assistance of other health care professionals
A. Collaborative problem
B. Referral problem
B. Referral problem
Assessing whether outcome criteria have been met and revising the plan of care if necessary
A. Nursing assessment
B. Evaluation
C. Nursing diagnostic phase
D. Implementation
B. Evaluation
Clinical judgement about individual, family, or community responses to actual or potential health problems and life processes
Nursing diagnosis
(collaborative problem or referral)
Findings directly observed or indirectly observed through measurements (e.g., body temperature)
Objective data
Physiologic complications that nurses monitor to detect their onset or changes in status
Collaborative problem
What are some things that need to be validated ?
- discrepancies or gaps between subjective & objective data
ex: client says that he’s happy, despite learning that he has terminal cancer - discrepancies or gaps between what the patient says at one time vs another time
- findings that are highly abnormal
It is the nurse’s job to identify areas in which data are missing… provide an example
98 lbs adult patient … nurse needs to know if the patient has always been that size, or is he depressed, or being abused etc.
__________ are designed to ensure that the nurse gathers pertinent information needed to meet standards and guidelines of other institutions, and to develop a plan of care for the client. It involves both comprehensive, health, & medical records.
electronic health records “EHR
Promotes the adoption and meaningful use of health information technology (HIT)
Health Information Technology for Economic and Clinical Health Act (HITECH Act)
Most data start with __________ data and end with _________ data.
subjective
objective
What are the two key things that need to be included in every documentation?
Nursing history (subjective)
Physical assessment (objective)
The nurse should document only what the client tells, and what the nurse observes, not what the nurse interpret or infer from the data. (T/F)
True
Biographical data, present health concerns/symptoms, personal health history, family history, and lifestyle & health practices are examples of _________ data.
subjective
A physical examination, which include inspection, palpation, percussion, auscultation & etc. are examples of _________ data.
objective
It is important to document using descriptive words rather than non-descriptive words. (T/F)
True
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is…
ongoing & continuous
Health assessment is divided into four steps:
- collecting subjective data
- collecting objective data
- validation of data
- documentation of data
What are the 4 types of nursing assessment?
- initial comprehensive
- ongoing or partial
- focused or problem oriented
- emergency
A(n) _____________ assessment involves collection of subjective data about the client’s perception of his or her health of all body parts & systems, past health history, family health history, and lifestyle and health practices as well as objective data
initial comprehensive
