chapter 16/17/18/19/20 Flashcards
medical diagnoses
statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession
nursing diagnoses
actual or potential health problem that an independent nursing intervention can prevent or resolve
risk nursing diagnosis
clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation
health promotion nursing diagnosis
behavior of an individual motivated by a personal desire to increase well-being and health potential
PPMP
predicts the most common complications, prevent them, manage them if cant prevent, and promote optimum function
Nursing Interventions Classification (NIC)
first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions
Nursing Outcomes Classification (NOC)
developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention
nurse-initiated intervention
independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs
physician-initiated interventions
dependent nursing actions, involving carrying out physician-prescribed orders
initial planning
developed by the nurse who performs the nursing history
ongoing planning
carried by any nurse who works with the patient, keeps plan up to date and states problems more clearly
discharge planning
carried out by the nurse who worked most closely with the patient and begins when the patient is admitted
Which nursing action would most likely occur during the ongoing planning stage?
the nurse collects new data and uses them to update the plan
cognitive outcomes
describes increase in patient knowledge or intellectual behaviors
psychomotors
patient achievement of new skills
affective outcomes
change in patient values, beliefs, and attitudes
What is an effective affective outcome?
By 6/9/19, the patient will verbalize valuing his health enough to stop smoking.
collaborative intervention
initiated by other providers and carried out by a nurse
standing orders
detail nursing activities which can be initiated in specific situations without the order or supervision of a health care provider.
adverse reaction
an adverse reaction is an unwanted or harmful reaction experienced following the administration of a drug, diagnostic test, or therapeutic intervention under normal conditions of use.
direct care intervention
treatment performed through interaction with the patient
indirect care intervention
treatment performed away from the patient but on behalf of a patient or group of patients
scope of practice
The American Nurses Association states that the Nursing Scope and Standards of Practice describe the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice in keeping with the terms of their professional license.
National Database of Nursing Quality Indicators
indicators aimed at promoting and facilitating the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes
cognitive outcome
increase in patient knowledge
psychomotor
patients achievement of new skills
affective
changes in patient values, beliefs, and attitudes
physiologic
physical changes in patient
bedside report
standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family
change-of-shift report
communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care;
charting by exception (CBE)
shorthand method for documenting patient data that are based on well-defined standards of practice, only focuses on a specific problem and not the body as a whole
electronic health records
digital version of a patient’s chart that may contain the patient’s medical history, diagnoses, medications, treatment plan
graphic record
form used to record specific patient variables
health information exchange
an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information
incident report
a report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor
Outcome and Assessment Information Set (
assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided
problem-oriented medical record (
documentation system organized according to the person’s specific health problems;
read back
a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted
Verbal Order Guidelines
must be given by the physician or nurse practitioner
-record in patient record with initials “VO”
-read back to verify
Which method of documentation is unique in that it does not develop a separate course plan but incorporates it into the progress notes?
PIE
genomics
study of the structure and interactions of all genes in the human body, including their interactions with each other as well as the environment;
nursing informatics
the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
pharmacogenomics
use of information about a person’s genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that person
telehealth
the use of electronic info and telecommunications to support and promote long distance
telemedicine
the use of telecommunications technologies to support the delivery of all types of medical
telecare
refers to technology that allows consumers to stay safe and independent in their own homes
