Week 9: Nursing assessment, diagnosis and planning

Question 1

5 steps in nursing process

Answer 1

Assessment, Diagnosis, Planning, Implementation and Evaluation

Question 2

which step involves critical thing and data collection?

Answer 2

assessment

Question 3

Types of data in assessment

Answer 3

Subjective (e.g. I have pain in my chest) and Objective (e.g BP 162/90)

Question 4

Sources of data in assessment

Answer 4

Client (primary), Secondary sources: family and significant other, health care team, medical records

Question 5

Ways to collect data in assessment

Answer 5

interview, physical examination, form completion, nursing health history, family history

Question 6

what is a diagnosis?

Answer 6

1. Nursing diagnosis: a clinical judgement about client responses to an actual or potential health problem
2. Medical diagnosis: the identification of a disease condition on the basis of specific evaluation of signs and symptoms
3. Collaborative Problem: an actual or potential complication that nurses monitor to detect a change in client status

Question 7

which step involves analyzing data, identifying health problems and forming diagnostic statements?

Answer 7

Nursing diagnosis

Question 8

what is diagnostic reasoning?

Answer 8

a process of using assessment data to create a nursing diagnosis.

Question 9

what are defining characteristics?

Answer 9

clinical criteria or assessment findings that help confirm an actual nursing diagnosis

Question 10

what is clinical criteria?

Answer 10

Objective or subjective signs and symptoms that lead to a diagnostic conclusion

Question 11

What are the types of nursing diagnosis?

Answer 11

Actual/problem-focused nursing diagnosis, Risk nursing diagnosis, Syndrome nursing diagnosis, Health promotion/wellness nursing diagnosis and Possible nursing diagnosis

Question 12

A nursing diagnosis comprises of?

Answer 12

1. The problem or diagnostic label (has two components: qualifier and focus of the diagnosis)
2. The related factor (written as “related to”)
3. The defining characteristics (written as “as evidenced by”)

Question 13

which step has to do with formulating goals and expected outcomes?

Answer 13

Planning

Question 14

Classification of priorities

Answer 14

high-priority nursing diagnoses, intermediate-priority nursing diagnoses and low-priority nursing diagnoses

Question 15

3 phases in setting priorities

Answer 15

initial, ongoing and discharge

Question 16

what is client goal?

Answer 16

A specific, measurable outcome/behaviour or response reflecting client’s highest
possible wellness level and independence

Question 17

what is short-term goal?

Answer 17

An objective outcome/behaviour or response expected within hours to a week

Question 18

what is long-term goal?

Answer 18

An objective outcome/behaviour or response expected within days, weeks, or months

Question 19

what are expected outcomes?

Answer 19

Specific, measurable (objective) change in a client’s status that is expected in response to nursing care

Question 20

Care plans may be referred to as?

Answer 20

o Nursing care plan
o Institutional care plans
o Computerized care plans
o Care plans for community-based settings
o Critical/clinical pathways