NURS 210 W3

objective data

physical assessment, lab/diagnostic testing, can be measured or observed, may validate subjective data

subjective data

provide patient perspective, can’t be validated by a test

primary source

patient

secondary source

source other than patient (parent, guardian, etc)

validation

For data that doesn’t have sufficient proof or where there are discrepancies between subjective (patient statements) and objective (measurable) data, or when findings are abnormal

medical model

This model involves a medical diagnosis of a condition

nursing model

The nursing scope, the “caring” model of diagnosis - physical, psychological, social response

Actual

This type of nursing diagnosis involves a problem response that exists at the time of assessment, signs and symptoms are present

Risk

This type of nursing diagnosis is a problem that is likely to develop without intervention. Risk factors are present but there are no signs or symptoms. Patient is more highly susceptible than others

Wellness

This type of nursing diagnosis addresses a heath status rather than a problem

etiology

the ____ of the nursing diagnosis is NEVER the medical diagnosis (EX nursing dx - pain. Medical dx - myocardial infarction. cause of nursing dx - ischemia)

Readiness

This is a key word for wellness related nursing DX word

Wellness

Readiness for Enhanced Self Management is an example of what type of nursing dx?

ABCs

Prioritization in nursing acronym

Airway

The A of ABCs

B

The B of the ABCs

Circulation

The C of the ABCs

Safety and pain

Beyond the ABCs, what is our next priority

Patient Centered

The P of P-SMART Goals

Specific

The S of the P-SMART Goals

the patient will

All P-Smart goals should start with this phrase

observable, measurement

P-Smart Goal Formula = The patient will + 1 _____ action + a ______ + timeframe

Measurable

The M of P-Smart Goals

Attainable

The A of P-SMART goals

Relevant

The R of P-SMART goals

Timely

The T of P-SMART Goals

Risk factors

Many nursing goals are centered on reducing ___ ____