Module 4

Question 1

describe the assessment phase

Answer 1

systematic collection, organization, validation and documentation of patient data

Question 2

describe baseline data

Answer 2

initial information before any interventions, or treatments are made. it provides a point of reference for nurse

Question 3

describe the evaluation phase

Answer 3

compares patient’s current health with the desired outcome- this is important to determine if the care plan is appropriate, working or needs revision

Question 4

define goals

Answer 4

established focus on what the patient will be able to do or achieve

Question 5

define health history

Answer 5

record of individuals’ past and present health information- gives a background to healthcare providers about patient and their background

Question 6

describe the implementation phase

Answer 6

apply knowledge, skills and principles to move patient toward optimal wellness. It involves action.

Question 7

what is nursing diagnosis

Answer 7

clinical judgement of a patient’s actual or potential health problem that is within the nurses’ scope of practice to address.

Question 8

what is the nursing process

Question 9

clinical judgment measurement model (CJMM)

Question 10

describe objective data

Answer 10

gathered through physical assessment, lab tests, other diagnostic sources. Anything you can see, touch, smell, hear. (I can touch, see an object)

Question 11

what are outcomes

Answer 11

specific criteria used to measure attainment of selected goals

Question 12

describe the planning phase

Answer 12

prioritizes diagnoses, formulates desired outcomes, and selects nursing interventions- assisting optimal level of wellness. Involves 2 components: drug administration and patient teaching

Question 13

describe subjective data

Answer 13

what the patient says or perceives. Ex) people talk in subjects, subjects come out of people’s mouths when they talk