Chapter 2 Nursing Process Key Terms Flashcards
Assessment
It is the systematic collection of facts or data.
Collaborative problems
Are there potential complications from a disorder, test, or treatment that the nurse cannot treat independently, such as bleeding? They represent an interdependent domain of nursing practice.
Concept Mapping
Also known as care mapping, it is a method of organizing information in graphic or pictorial form. It is created by identifying a main subject with interconnected links to related components.
Critical Thinking
Which is a process of objective reasoning or analyzing facts to reach a valid conclusion.
Database or Initial Assessment
Initial information about the client’s physical, emotional, social, and spiritual health.
Diagnosis
It is the identification of health-related problems.
Evaluation
It is how nurses determine whether a client has reached a goal.
Focus Assessmsnt
It is information that provides more details about specific problems and expands the original database.
Functional Assessment
is a comprehensive evaluation of a client’s physical strengths and weaknesses in areas such as;
(1) the performance of activities of daily living;
(2) cognitive abilities;
(3) social functioning.
Goals
Identify specific evidence for each nursing diagnosis that a client’s problem is trending toward resolution or has been resolved.
Health Promotion Diagnosis
A concern with which a healthy person desires nursing assistance to maintain or achieve a higher level of wellness.
Implementation
This means carrying out the plan of care.
Long term Goals
These outcomes take weeks or months to accomplish for clients with chronic health problems who require extended care in a nursing home or who receive community health or home health services.
NANDA International
It is the authoritative organization for developing and approving nursing diagnoses.
Nursing Care Plans
Written assignments on standardized worksheets contain a column for nursing diagnoses, outcome criteria, nursing interventions, and the rationale for each intervention for each assigned client.
Nursing Diagnosis
A health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures.
Nursing Orders
Directions for a client’s care within a nursing care plan: identify the what, when, where, and how of performing nursing interventions.
Nursing Process
It is an organized sequence of problem-solving steps used to identify and manage clients’ health problems.
Objective Data
Observable and measurable facts.
Outcome Criteria
Sometimes called goals, identify specific evidence for each nursing diagnosis that a client’s problem is trending toward resolution or has been resolved.
Planning
The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable expected outcomes, selecting appropriate interventions, and documenting the plan of care.
Problem Focus Diagnosis
A problem that currently exists.
Risk Diagnosis
A problem the client is uniquely at risk of developing.
Short Term Goals
Outcomes are achievable in a few days to 1 week more often in acute care settings because most hospital stays are only a few days or no longer than one week.
Signs
An example is a client’s blood pressure measurement.
Standards of Care
Policies that indicate which activities will be provided to ensure quality client care and clinical pathways relieve the nurse from writing time-consuming plans.
Subjective Data
Information that only the client feels and can describe.
Symptoms
an example is pain.
Syndrome Diagnosis
A cluster of problems related to an event or situation that can be managed together.
The Joint Commission
A not-for-profit organization accrediting health care organizations in the United States requires that every client’s medical record provides evidence of the planned interventions for meeting the individualized client’s needs, but not necessarily a nursing plan of care.
