Nursing Process - Answers Assess, Diagnose, Plan, Implement, Evaluate
CJMM - Answers Recognize cues, analyze cues, prioritized hypotheses, generate solutions, take
action, evaluate outcomes
Assessment - Answers recognition: collection and verification of data
analysis of data
Primary data - Answers From patient (interview, observation physical exam, labs, scans)
Secondary data - Answers family and significant others
health care team
medical records
Subjective data - Answers pt's POV
collected via interview
Objective data - Answers observable and measurable data
collected by physical exam, vital signs, labs, and scans
Pt centered interview - Answers assessment
phases: orientation and setting agenda, working phase, termination
Periodic assessments - Answers make during rounding or administering (safety checks, pain)
Physical exam - Answers focused or comprehensive
Positive interviewing techniques - Answers observation, open ended questions, back channeling
(show attentiveness), probing (tell me more), clarifying, summarizing
Negative interview techniques - Answers leading questions, closed ended questions, multiple
questions, interrupting, judgmental questions (why?)
Analysis - Answers organizing data to identify patterns
ensuring data and completeness
Cue - Answers information that you pick up on
Cue clustering - Answers putting cues together that could mean the same thing
Inference - Answers judgment or interpretation of these cues
Assessment importance - Answers foundation of care planning: accurate assessment is crucial
Individualized care: tailors care to meet specific pt needs
early detection: identifies potential health issues early
informed decision making: provides necessary information for evidence based decisions
Develop Hypothesis - Answers interpret meaning of data
identify problem
Medical diagnosis - Answers identification of a disease based off the physicalassessment/signs and
symptoms, results of diagnostic tests/ procedures.
done by provider
Nursing diagnosis - Answers made by an RN that describes a pts response or problem or
theirvulnerability to health conditions
Having this helps nurse to nurse communication to help understand a patients need
Collaborative problem - Answers require both nursing and medical interventions
collaborative problems using nursing and physician-prescribed interventions to reduce the
complications of the event
NANDA international - Answers develops, researches, disseminates, and refines the terminology of
nursing diagnoses
Established in 1982 to standardize nursing terminology
Importance of nanda in diagnoses - Answers standardization: provides standardized language and
consistency for nursing communication
guidance for care planning: helps in identifying accurate nursing diagnoses and guiding development
of care plans
evidence based practice: supports best practices in pt care
improved pt outcomes: leads to effective and targeted interventions
Prioritize hypothesis - Answers A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure