Chapter 4 Flashcards
Analysis
Using data to determine patient need or nursing diagnosis
Assessment
Collection of subjective and objective data
Evaluation
Decision making process determining the effectiveness of nursing actions or interventions
Expected outcome
Expected behavior and physical and mental state of the patient after a therapeutic intervention
Implementation
Carrying out of a plan of action
Independent nursing actions
Actions that do not require a physicians orders
Initial assessment
Gathering of baseline data
Nursing diagnosis
Description of patient problem
Nursing process
Framework for nursing action, consisting of a series of problem solving steps which helps members of the health care team provide effective and consistent patient care
Objective data
Information obtained through a physical assessment or physical examination, lab tests, or scans
Ongoing assessment
Continuing assessment activities that proceed from the initial nursing assessment
Planning
Design of steps to carry out nursing actions
Subjective data
Information supplied by the patient or family
