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Test 1 400 Nursing L.A. Pierce College
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Test 1 400 Nursing L.A. Pierce College
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Test 1 400 Nursing L.A. Pierce CollegeSubjective data - ANS-Subjective data are the facts presented by the patient that show
his or her perception, understanding, and interpretation of what is happening. An
example of subjective data is the patient's statement, "The pain begins in my lower back
and runs down my left leg."
or, Things a person tells you about that you cannot observe through your senses;
symptoms
Objective data - ANS-Objective data are facts that are observable and measurable by
the nurse. These data are gathered by the nurse through physical assessment,
interviewing, and observing, and involve the use of the senses of seeing, hearing,
smelling, and touching. An example of objective data is the measurement and recording
of vital signs. Objective data are also gathered through such diagnostic examinations as
laboratory tests, x-ray examinations, and other diagnostic procedures.
Nursing process - ANS-Assessing: Collecting, organizing, validating and documenting
client data
Diagnosing: Analyzing and synthesizing data
Planning: Determining how to prevent, reduce, or resolve the identified priority client
problems; how to support client strengths; and how to implement nursing interventions
in an organized, individualized, and goal-directed manner
Implementing: Carrying out (or delegating) and documenting the planned nursing
interventions
Evaluating: Measuring the degree to which goals/outcomes have been achieved and
identifying factors that positively or negatively influence goal achievement.
Assessment - ANS-The first step, or phase, of the nursing process is assessment.
During this phase, you are collecting data (factual information) from several sources. It
includes subjective and objective data.
Assessing is the systematic and continuous collection, organization, validation, and
documentation of data. A
Assessing is a continuous process carried out during all phases of the nursing process.
All phases of the nursing process depend on the accurate and complete collection of
data.
Assessment-screening-for future ER - ANS-screening, problem-based/focused health
assessment, comprehensive health assessment, episodic assessment
, Assessment-Four Types - ANS-initial nursing assessment, problem focused
assessment, emergency assessment, and time-lapsed re-assessment.
Assessments vary according to their purpose, timing, time available, and client status.
Nursing Assessment - ANS-Nursing assessments focus on a client's responses to a
health problem. A nursing assessment should include the client's perceived needs,
health problems, related experience, health practices, values, and lifestyles. To be most
useful, the data collected should be relevant to a particular health problem. Therefore,
nurses should think critically about what to assess.
Goal nursing - ANS-Expected outcomes are clearly stated in terms of patient behavior
or observable assessment factors.
Expected outcomes are realistic, achievable, safe, and acceptable from the patient's
viewpoint.
Expected outcomes are written in specific, concrete terms depicting patient action.
expected outcome/goal - ANS-specific statement of the goal the patient is expected to
achieve as a result of nursing intervention. Should be realistic and attainable and should
have a defined time line
NOC states that outcomes among other things, should be: Concise, Not describe nurse
behaviors or interventions, Describe a state, behavior, or perception that is inherently
variable and can be measured and quantified. Expected outcomes are directly
observable by use of at least one of the five senses.
medical asepsis - ANS-practices used to remove or destroy pathogens and to prevent
their spread from one person or place to another person or place; clean technique
medical asepsis - ANS-infection-control practices common in healthcare, such as basic
handwashing
implementation/intervention - ANS-The fourth step of the nursing process, the nurse
initiates the interventions that are most likely to achieve the goals and expected
outcomes needed to support or improve the client's health status.
intervention - ANS-the performance of nursing interventions necessary for achieving the
goals and expected outcomes of nursing care
evaluation - ANS-the last phase of the nursing process in which the nurse determines if
identified outcomes have been met and the overall accuracy of the assessment,
diagnosis, and implementation phases is evaluated.
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