1.

Define nursing assessment.

The nursing assessment is the gathering of information about a patient's

physiological, psychological, sociological, and spiritual status. This allows the nurse
to make a judgment about the patients health status and ability to manage their
own care, and referring the patient to a physician
2.

Discuss a critical thinking approach to assessment.

A critical thinking approach to assessment could be detecting bias and

determining the credibility of information, distinguishing normal from abnormal and
identifying the risks for abnormal findings, making judgments about the significance
of data, identifying assumptions and inconsistences.
3.

Differentiate subjective data, objective data

Subjective data is information perceived by the affected person. It could be

called symptoms or convert data. Examples could include experiencing pain or
feeling nervous. Objective data are measurable and observable data that can be
seen, heard, or felt by someone other than the person experiencing them. It can be
also called signs or overt data.
a.

Primary sources/types and secondary sources of data collection.

4.

Identify sources and methods of data collection.

Sources: patient, family and significant others, patient record. Methods:

observation, nursing history, patient history, nursing physical assessment
5.

Differentiate open and closed ended questions.

6.

Explore cultural considerations of data collection.

Important to remember all ways that cultural factors can influence the process of
assessment. Beliefs, practices, habits, likes, dislikes, customs.
7.

Explore the components of a nursing heath history.

Profine, reason for seeking healthcare, normal health habits, cultural considerations,
current meds, allergies,
8.
Discuss the criteria associated with assessment data validation and nursing
inferences.
Identify cues, make inferences about cues, validate cues and inferences.

9.

10.

Examine the nursing process and its relation to critical thinking

Compare the nursing process and the decision-making process.

Decision making- choosing from options, a purposeful, goal directed effort applied in
a systematic way to make a choice among alternatives.
Nursing process- systematic method that directs the nurse and patient through
assessment, nursing diagnosis, identifying expected outcomes and plan care,
implementing, and evaluation.
Diagnosis
1.

Define nursing diagnosis.

Clinical judgment to Actual or potential health problems that can be prevented or

resolved by independent nursing intervention.
2.
Differentiate various types of nursing diagnoses. NANDA (North American
Nursing Diagnosis Association).
Actual- represent a problem that has been validated by the presence of major
defining characteristics.
Risk- clinical judgments that an individual family, or community is more vulnerable
to develop the problem than others in the same or similar situation.
Possible- statements describing a suspected problem for which additional data are
needed.
3.

Examine the components of a nursing diagnosis.

Assessing, diagnosing, planning, implementing, evaluating

4.
Differentiate between nursing
collaborative problems

diagnosis, medical diagnosis,

and

nursing
- Actual or potential health problems that can be prevented or resolved
by independent nursing intervention.
Medical- identifying diseases, describe problems for which the physician directs the
primary treatment.
Collaborative- certain physiologic complications that nurse monitor to detect onset
or changes in status.
5.

Describe the diagnosis formulation process.

Interpret and analyze patient data, patient strengths and health problems,
formulate and validate nursing diagnoses, develop a prioritized list of nursing
diagnoses, detect and refer signs and symptoms that may indicate a problem
beyond nurses experience
6.

Identify common errors of the nursing diagnostic process.

Premature diagnoses based on an incomplete database, erroneous diagnosis

resulting from an inaccurate database, routine diagnoses from nurses failure to
tailor data collection and analysis to the unique needs of the patient., errors of
omission
7.

Apply critical thinking to the nursing diagnostic process.

Familiar with nursing diagnoses and other health problems, trust clinical experience
and judgment but willing to ask for help, respect clinical intuitions, keep an open
mind
8.
Examine the development of nursing diagnoses in care planning or concept
mapping.

Planning
1.

Define planning.

Establish patient goals to prevent, reduce, or resolve the problems identified in the
nursing diagnoses and determination of related nursing interventions.
2.

Identify priority practices associated with planning.

Maslows hierarchy of human needs, patient preference, anticipation of future

problems
3.

Discuss types of nursing care plans.

Kadex, computerized, case management , concept map

4.

Explain the use of a nursing Kardex care plan.

Plan of care recorded in a folded card and placed in a central Kadex file eventually
on patients health record. Outside of card contains basic information such as
profile , admitting diagnosis, activity levels, diet, and routine treatments inside has
nursing care plan specifying the very minimum nursing diagnoses or health
problems and related outcomes.
5.

Explore standardized

approaches to care planning.

6.

Explain multidisciplinary (collaborative) care plans.

Carrying out treatments initiated by other providers like pharmacists, respiratory

therapists, or PA assistants.
7.

Examine guidelines for writing nursing care plans.

Pg 276
8.

Discuss criteria in establishing client goals/desired outcomes.

Safe: avoiding injury; effective: avoiding overuse and underuse; patient centered:
responding to patient preferences, needs, and values; timely: reducing waits and
delays; efficient: avoiding waste; equitable: providing care
9.

Differentiate between long-term and short-term goals.

Long term: require longer than a week, may be used as discharge goals and broadly
written and communicate to the entire nursing team the desired end results.
10.

Explain the relationship of outcome criteria to clients goals

11.
Identify how to write goals and expected outcomes associated with care
planning.

12.

Explore the critical thinking approach to nursing interventions.

13.

Discuss the process of

selecting nursing interventions and strategies.

Appropriate in terms of nursing diagnosis and related patient outcomes, safe, and
efficient; consistent with research findings and standards of care; realistic in terms
of the abilities, time, and resources available to the nurse and patient; compatible
with the patients values, beliefs, and cultural and psychosocial background; valued,
whenever possible by the patient and family; compatible with other planned
therapies.
14.

Explore NIC/NOC (Nursing Outcomes/Interventions Classification).

NIC: first comprehensive, validated list of nursing interventions applicable to all

settings that can be used by nurses in multiple specialties, greatly facilitates the
work of identifying appropriate interventions.

Nanda
Examples of corrects way to write nursing diagnoses
Medical vs nursing diagnoses
Ology
Prefix suffix for pain
Doctors order vs nurses order
ADPIE
Change of shift report