CH 16-20 Flashcards
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| Assessment</p>
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first step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification</p>
Nursing health history
Data collected about a patient’s present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness
Nursing process
systematic problem-solving method by which nurses individualize care for each patient. ADPIE
Objective data
Information that can be observed by others; free of feelings, perceptions, prejudices
Standards
actions that ensure safe nursing practice
Subjective data
information gathered from patient statements; the patient’s feelings and perceptions. Not verfiable by another except by inference
Nursing diagnosis
judgement that is clinically validated by the presence of major defining characteristics
Client-centered problems
problems involving the client
Defining characteristics
Related signs and symptoms or clusters of data that support the nursing diagnosis
Diagnostic label
the name of the nursing diagnosis
Etiology
study of all factors that may be involved in the development of a disease
Medical diagnosis
formal statement of the disease entity or illness made by the physician or health care provider
NANDA International
North American Nursing Diagnosis Association International
Related factor
any condition or event that accompanies or is linked with the patient’s health care problem
Risk for nursing diagnosis
Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community
Client-centered goal
reflects a patient’s highest possible level of wellness and independence in function
Collaborative intervention
Therapies that require the knowledge, skill, and expertise of multiple health care professionals
Critical pathway
tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay
Dependent nursing intervention
aka physician-initiated interventions
Expected outcome
measurable criterion to evaluate goal achievement
Independent nursing intervention
aka nurse-initiated interventions or actions that a nurse initiates
Kardex
trade name for card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care
Long-term goal
objective behavior or response that you expect to achieve over a longer period, usually over several days, weeks, or months
Nursing care plan
a guideline for for coordinating nursing care
Priority setting
ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions
Clinical guideline
a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
Direct care
treatments performed through interactions with patients
Indirect care
treatments performed away from the patient but on behalf of the patient or group of patients
Implementation
initiation and completion of the nursing actions necessary to help the patient achieve health care goals
Interdisciplinary care plan
plans representing the contributions of all disciplines caring for a patient
Nursing intervention
any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes
Standing order
written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings
Outcome
an end result that is measurable, desirable, and observable and translates into observable patient behaviors
Outcome management
making sure that the proper steps are taken to ensure the outcome
Performance improvement
an organization analyzes and evaluates current performance and uses the results to develop focused improvements actions
Quality improvement
an approach to the continuous study and improvement for the processes of providing health care services to meet the needs of patients and others and inform health care policy
Standard of care
minimum level of care accepted to ensure high-quality care to patients. standards of care define the types of therapies typically administered to patients with defined problems or needs
