Steps of the Nursing Process Correct Answer: Assessment - gather data
Diagnosis - problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatment plan, intervention
Implementatio
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Steps of the Nursing Process Correct Answer: Assessment - gather data
Diagnosis - problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatment plan, intervention
Implementation - doing the plan
Evaluation - Was it successful, meet the goals
Define Subjective Data Correct Answer: What patient says about himself or herself during history taking
symptoms
Define Objective Data Correct Answer: Observed when inspecting, percussing, palpating, and
auscultating patient during physical examination
signs
Factors of Diagnosis Correct Answer: -Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy
-Look for gaps in your information
-Interpret data and identify problems
-Document the diagnosis
Factors of Outcome Identification Correct Answer: -Identify expected outcomes related to patient
individualization
-Ensure outcomes have the SMART components
-Specify short-term and long-term goal measurement criteria
What does SMART stand for? Correct Answer: Specific, Measurable, Attainable, Realistic, Timely
Factors of Planning Correct Answer: -Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members for the patient
-Document plan of care
Factors of Evaluation Correct Answer: -Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome: does something need to be done
-If NOT reached: identify reasons for not achieving
-Modify plan if needed
-Document in plan of care
Evidence-Based Decision Making factors Correct Answer: -Best evidence from clinical review of research
literature
-The providers clinical expertise
-Patient's preference and values
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