What is the nursing process? Right Ans - A systematic problem-solving
process that guides all nursing actions
Involves thinking and doing
What are the steps of the nursing process Right Ans - Assessment
Analysis
Planning
Implementation
Evaluation
What occurs during the assessment phase? Right Ans - The nurse is
noticing what is going on with the patient
What occurs during the analysis phase? Right Ans - The nurse is
interpreting what is going on with the patient through reviewing lab work,
etc. — identifying the problem
What occurs during the planning and implementation phase? Right Ans -
The nurse is responding to the patients needs through prioritization — setting
the goals for what you are going to do and providing the care
What occurs during the evaluation phase? Right Ans - The nurse is
reflecting on the care given to the patient — did my patient receive the best
care?
Describe step 1: Assessment Right Ans - Systematic gathering of
information related tot he physical, mental, spiritual, socioeconomic, and
cultural status of an individual, group, or community
What does assessment include? Right Ans - Collecting data using a
systematic and ongoing process
Categorizing data — physical/mental/economic/social data
Validating data
Recognizing cues (subjective/objective data) related to the clients condition
Recording the data collected — documentation
, What are the different types of data? Right Ans - Objective
Subjective
Primary
Secondary
Define subjective data Right Ans - Information that patients offer about
their condition. (symptoms)
Ex: "my stomach hurts" or "i feel nauseous"
Define objective data Right Ans - Obtained through physical assessment;
diagnostic tests; lab work (signs)
Ex: pulse is 84 — rash on right forearm — chest x-ray report
Define primary data Right Ans - Objective or subjective data obtained
directly from the patient
Define secondary data Right Ans - "Second hand" data — obtained by
medical records, diagnostic tests, another caregiver
What are some sources of data? Right Ans - Patient
Family or significant other
Health care team
Medical records
Nurses observation
What are the types of assessments? Right Ans - Initial
Ongoing
Comprehensive
Focused
Define initial assessment Right Ans - Completed at first contact with
patient/client
Define ongoing assessment Right Ans - Continuous — to asses patients
condition, evaluate status of existing problem and if goals are met
Ex: you inhibit pain medication to a patient, you return to their room in 30
minutes to see if their pain level has decreased
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