Ch. 17 & 18 Flashcards
Collaborative problem
Physiological complication that requires the nurse to use nursing and health care provider-prescribed interventions to maximize patient outcomes.
Data cluster
Set of signs or symptoms that are grouped together in logical order.
Defining characteristics
Observable assessment cues such as patient behavior, physical signs that support each problem-focused diagnostic judgement.
Diagnostic label
Is the name of the nursing diagnosis as approved by North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of a patient’s response to health conditions in as few words as possible.
Health promotion nursing diagnosis
Is a clinical judgment concerning a patient’s motivation and desire to increase well-being and actualize human health potential.
Medical diagnosis
Formal statement of the disease entity or illness made by the physician or health care provider.
North American Nursing Diagnosis Association International (NANDA-I)
It is an organization that formally identifies, develops, and classifies nursing diagnoses.
Nursing diagnosis
Formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step of the nursing process, during which the patient’s actual and potential unhealthy responses to an illness or condition are identified.
Problem-focused nursing diagnosis
Describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.
Related factor
Any condition or event that accompanies or is linked with the patient’s health care problem.
Risk nursing diagnosis
A clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes.
Collaborative interventions
Therapies that require the knowledge, skill, and expertise of multiple health care professionals.
Consultation
Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs.
Dependent nursing interventions
The interventions that initiated by Health care provider or actions that require an order from a health care provider.
Expected outcome
Expected conditions of a patient at the end of therapy or a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education.
Goal
Desired results of nursing actions set realistically by the nurse and patient as part of the planning stage of the nursing process.
Independent nursing interventions
Nurse-initiated interventions or actions that a nurse initiates without supervision or direction from others.
Interdisciplinary care plans
Contributions from all disciplines involved in patient care. It focuses on patient priorities and improves the coordination of all patient therapies and communication amount all disciplines.
Long-term goal
Is an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months.
Nursing care plan
Includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation.
Nursing Outcomes Classification
A systematic organization of nurse sensitive outcomes into groups or categories based upon similarities, dissimilarities, and relationships among the outcomes.
Nursing Interventions Classification (NIC)
A set of nursing interventions that provides a level of standardization to enhance communication of nursing care across all health care settings and compare outcomes. The NIC model includes 3 levels: domains, classes, and interventions for ease of use.
Patient-centered goal
Reflects a patient’s highest possible level of wellness and independence in function. It is realistic and based on patient needs, abilities, and resources.
Planning
Process of designing interventions to achieve the goals and outcomes of health care delivery.
Priority Setting
Is the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.
Nursing-sensitive patient outcomes
Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient’s symptoms, functional status, safety, psychological distress, or costs.
Scientific rationale
Reason why a specific nursing action was chosen based on supporting literature.
Short-term goal
Is an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours.
