Summary NUR 641E
- Midterm Exam
Study Guide.
subjective data
What patient says about himself or herself during history taking
objective data
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
Database
formed from these elements, plus patient's record and laboratory studies
,Diagnostic reasoning
a dynamic thinking process that leads to the identification of a hypothesis that best explains the clinical
evidence
Steps of the Nursing Process
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Assessment
- collect data from multiple sources
- use evidence-based assessment
- document relevant data
Steps of assessment collection
1. Review of clinical record
2. Interview
3. Health history
, 4. Physical examination
5. Functional assessment
6. Cultural and spiritual assessment
7. Consultation
8. Review of the literature
Nursing Process: Diagnosis
- Interpretation of data by identifying clusters of cues so as to make inferences
- Compare clusters of cues with definitions and defining characteristics
- Validation of inferences based on findings
- Identify related factors
- Document the diagnosis
Nursing Process: Outcome Identification
-identify expected outcomes related to individualization
- ensure outcomes are realistic and measurable
- specify short-term and long-term goal measurement criteria
Nursing Process: Planning
- Midterm Exam
Study Guide.
subjective data
What patient says about himself or herself during history taking
objective data
Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
Database
formed from these elements, plus patient's record and laboratory studies
,Diagnostic reasoning
a dynamic thinking process that leads to the identification of a hypothesis that best explains the clinical
evidence
Steps of the Nursing Process
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Assessment
- collect data from multiple sources
- use evidence-based assessment
- document relevant data
Steps of assessment collection
1. Review of clinical record
2. Interview
3. Health history
, 4. Physical examination
5. Functional assessment
6. Cultural and spiritual assessment
7. Consultation
8. Review of the literature
Nursing Process: Diagnosis
- Interpretation of data by identifying clusters of cues so as to make inferences
- Compare clusters of cues with definitions and defining characteristics
- Validation of inferences based on findings
- Identify related factors
- Document the diagnosis
Nursing Process: Outcome Identification
-identify expected outcomes related to individualization
- ensure outcomes are realistic and measurable
- specify short-term and long-term goal measurement criteria
Nursing Process: Planning
