NURS 216: EXAM 1 WITH QUESTIONS AND 100% ALL SURE ANSWERS
Terms in this set (114)
Involves gathering data about the patient and their health status info is related to the
Assessment
physiological, psychological, sociological, development, and spiritual status of the individual.
Primary data Obtained directly from the patient subjective what the patient says/ tells you
objective What you can see for your self
Secondary data Obtained secondhand from the medical record or another care provider
Using critical thinking skill the nurse analysis the assessment to identify patterns in the data and
draw conclusions about the client health status ( strength, problems, and factors contributing to
Diagnosis
the problem). The purpose of diagnostic is to identify the client's health status accuracy is
essential because the diagnosis is the basis for planning patient centered goals/ interventions.
Nursing diagnosis A statement of patients health status that nurses can identify prevent, or treat independently.
Describe a disease, illness, or injury purpose is to identify a pathology so appropriate treatment
Medicaid diagnosis
can be given to cure the condition,
NURS 216: EXAM 1 Encompasses identifying goals and outcomes, choosing interventions, and creating nursing care
planning
plan.
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, Begins with the first client contact refers to the development of the initial comprehensive care
Initial planning
plan
Ongoing planning Change made in the plan allows you to prioritize the problem the client has
Process of planning a self care and continuity of care after the client leave the healthcare setting
Discharge planning promotes client progress towards health/disease management outside of facility care and
reduces chances of readmission to hospital care
The comprehensive central source of info needed to guide holistic, goal-oriented care to
Nursing care plan
address each client's independent nursing actions necessary.
Implementation interventions Involves preforming or delegating planning interventions, carries out the care plan.
Last step and carries out the care plan judgment about the client's progress towards desired
Evaluation health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the
healthcare setting.
Structure Evaluation Focuses on the setting in which care is provided
Focuses on the activities preform it does not describe the results of the activities preformed, it
Process evaluation
focuses on what was done and how well it was done
Focuses on the observable and measurable changes in the client's health status resulting from the
Outcomes Evaluation
care given
Systematic collection of information about clients present health statuses to identify needs and
Assessment/data collection
additional data to collect based on findings
Nurse use critical thinking skills to identify clients health statuses or problems, interpret or
Analysis/data collection monitor the collected database, reach an appropriate nursing judgment about health status, and
coping mechanisms, and provide directions for nursing care.
Nurse must establish priorities and optimal outcomes of care they can readily measure and
Planning evaluate theses established priorities and outcomes of client care then direct nurse in selecting
interventions to include in a plan of care to promote, maintain, or restore health.
Nurse base the care they provide on assessment data, analyses, and the plan of care they
developed in the previous step of the nursing process, they must use problem solving, clinical
Implementation judgment, and critical thinking to select and implement appropriate therapeutic interventions
using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain,
or restore health.
NURS 216: EXAM 1
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