Chapter 9 (Nursing Process) Vocab

Question 1

Assessment

Answer 1

the thorough, systematic, and deliberate collection of patient data

Question 2

Health History

Answer 2

Is comprehensive and includes info about the patients physical and developmental status, emotional health, social practices, goals, values, lifestyle, expectations about health care system

Question 3

Cue

Answer 3

information that you obtain through use of your senses

Anything a patient says and what you observe

Question 4

Inference

Answer 4

your judgement or interpretation of cues

Question 5

Two steps of the nursing process

Answer 5

1. Collection and verification of data from primary sources and secondary sources
2. Analysis of the data

Question 6

Two Types of Data

Answer 6

Subjective and Objective

Question 7

Subjective Data

Answer 7

• Patients’ verbal descriptions of their health problems

* Examples: Feelings of fear, anxiety, physical discomfort, mental stress

Question 8

Objective Data

Answer 8

• Observations or measurements of a patient’s health status

* Inspection of a wound, observations made about gait

Question 9

Open-Ended Questions

Answer 9

Questions that prompt patients to describe a situation in more than one or two words; not yes/no questions

Question 10

Back-channeling

Answer 10

The practice of giving positive comments such as “all right,” “go on,” or “uh-huh,” to the speaker.

Question 11

Closed-Ended Questions

Answer 11

Questions that limit answers to one or two words such as yes/no, a number, or a the frequency of a symptom

Question 12

Validation

Answer 12

(of assessment data) is the comparison of data with another source to confirm the data accuracy

Question 13

Phases of an Interview

Answer 13

Orientation Phase
Working Phase
Termination Phase

Question 14

Sources of Data

Answer 14

Patient
Family & Significant Other
Health Care Team
Medical Records
Other Records and Scientific Literature 
Nurse Experience

Question 15

Final Step of Assessment

Answer 15

Communicate the information and document the information

Question 16

Nursing Diagnosis

Answer 16

a clinical judgment about the patient in response to an actual or potential health problem

Provides the basis for selection of nursing interventions

Question 17

Medical Diagnosis

Answer 17

The identification of disease condition based on specific evaluation of physical signs, symptoms, history, and diagnostic tests and procedures

Question 18

Collaborative Problem

Answer 18

Actual or potential physiological complication that nurses monitor to detect a change in patient status

Question 19

Nursing Diagnostic Process

Answer 19

a process that requires the use of critical thinking to analyze and interpret assessment data to form a nursing diagnosis

includes data clustering, interpreting and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem

Question 20

Data Cluster

Answer 20

a set of signs or symptom gathered during assessment that you group together in a logical way

Question 21

Data Analysis 
(and interpretation)

Answer 21

involves recognizing patterns in clustered data, comparing them with standards, and coming to a conclusion about the patients response to a health problem

Question 22

NANDA International (NANDA-I) and nursing diagnosis

Answer 22

North American Nurse Diagnosis Association

Question 23

NANDA International and nursing diagnosis

Answer 23

Group that developed a model for organizing nursing diagnosis for documentation, auditing, and communication purposes

Question 24

Defining Characteristics

Answer 24

Observable cues and inferences (clinical criteria or assessment findings) that support an actual nursing diagnosis

The cues that cluster as manifestations of a problem-focused or health promotion diagnosis or syndrome

Question 25

Three types of nursing diagnoses

Answer 25

Problem Focused Risk Health Promotion

Question 26

Problem Focused Nursing Diagnosis

Answer 26

Clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community These diagnosis have sufficient assessment data to support them

Question 27

Risk Nursing Diagnosis

Answer 27

Clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to a health condition or life process

Question 28

Health Promotion Nursing Diagnosis

Answer 28

Clinical judgment concerning motivation and desire to increase well-being and actualize human health potential Supported by defining characteristics

Question 29

Risk Factors | that influence risk nursing diagnosis

Answer 29

the environmental, physiological, psychosocial, genetic, and chemical elements that place a person at risk for a health problem

Question 30

Components of a nursing diagnosis

Answer 30

Diagnostic Label Related Factor Definition the PES Format

Question 31

Related Factor

Answer 31

What explains why you chose the diagnostic label; it is associated with a patient’s actual or potential response to the health problem and can change by using specific nursing interventions

Question 32

Four Categories of Related Factors

Answer 32

pathophysiological (some sort of biological or psychological factor), treatment-related (treatment has weakened the patient), situational (environmental or personal), and maturational (things that happen as we mature)

Question 33

Etiology***

Answer 33

is always within the domain of nursing practice and a condition that responds to nursing interventions

Question 34

What is the PES format and what does it stand for?

Answer 34

The three part nursing diagnostic label P (problem), E (Etiology or related factors), S (symptoms or defining characteristics)

Question 35

Concept Map***

Answer 35

A graphical way of organizing and linking data about a patient's multiple diagnoses It helps you critically think about your patient's nursing diagnoses, their relationship to one another, and their effect on the nursing care plan

Question 36

Sources of Diagnostic Erros

Answer 36

Data Collection, interpretation and analysis, data clustering, and the diagnostic statement

Question 37

Planning

Answer 37

the 3rd step in the nursing process that involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions

Question 38

Goal (patient centered)

Answer 38

a broad statement that described a desired change in a patient's condition or behavior it is realistic and can be short term or long term

Question 39

Expected Outcomes

Answer 39

The measurable change in the patient that’s used to evaluate goal achievement

Question 40

Nursing-Sensitive Outcome

Answer 40

a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions Ex: reduction of pain severity, incidence of pressure injuries, and incidence of falls

Question 41

SMART Goals/Expectations

Answer 41

Specific, Measurable, Attainable, Realistic, Timed

Question 42

Scientific Rationale

Answer 42

The reason for the intervention

Question 43

Independent Nursing Interventions

Answer 43

"Nurse Initiated" - the actions that a nurse initiates Ex: raising head of bed while eating, giving a bath, explaining the side effects of a med

Question 44

Dependent Nursing Interventions

Answer 44

"Health Care Provider-Initiated" -- Actions that require an order from a health care professional Ex: giving a medication, preparing patient for diagnostic testing

Question 45

Collaborative Interventions

Answer 45

"Interdependent Nursing Interventions" —Therapies that required the combined knowledge, skill, and expertise of multiple health care professionals Ex: Recommendations from the dietician or therapist

Question 46

Nursing Care Plan

Answer 46

includes nursing diagnoses, goals and expected outcomes, and individualized nursing interventions.

Question 47

Interdisciplinary care plan

Answer 47

Contributions from all disciplines involved in patient care

Question 48

Consultation

Answer 48

the process by which you seek the expertise of a specialist, such as your nursing instructor or clinical nurse specialist, to identify ways to handle problems in patient management or in planning and implementation of therapies

Question 49

Implementation

Answer 49

The performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care

Question 50

Nursing Intervention

Answer 50

is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

Question 51

Direct Care Interventions

Answer 51

treatments performed through interactions with patients | Ex: med administration, insertion of IV catheter or counseling during times of grief

Question 52

Indirect Care Interventions

Answer 52

treatments performed away from but on behalf of the patient or groups of patients Ex: managing the patient's environment, documentation, interdisciplinary collaboration

Question 53

Clinical Practice Guideline

Answer 53

or protocol - is a systematically developed set of statements (policies and procedures)

Question 54

Care Bundle

Answer 54

a group of interventions when executed together result in better patient outcomes than when implemented individually ex: sepsis management, prevention of ventilator-associated pneumonia

Question 55

Standing Orders

Answer 55

Pre-printed document that contains orders for conducting routine therapies, monitoring guidelines, and diagnostic procedures for specific patients with identified clinical problems

Question 56

Nursing Implementation Skills

Answer 56

Cognitive, interpersonal, psychomotor

Question 57

Activities of Daily Living (ADLs)

Answer 57

Activities performed during the course of a day ex: ambulation, eating, dressing, grooming

Question 58

Instrumental Activities of Daily Living (IADLs)

Answer 58

more in-depth activities performed Ex: shopping, meal prep, handling finances, etc

Question 59

Counseling

Answer 59

Method that helps patients use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships

Question 60

Evaluation

Answer 60

the crucial step of determining whether a patient's condition or well-being improved after an intervention was delivered

Question 61

5 Elements of Evaluation Process

Answer 61

1) comparing achieved effect with goals and outcomes 2) Collecting data to determine if your patient met the criteria or standards 3) interpreting and summarizing findings 4) recognizing errors or unmet outcomes 5) revising the care plan as needed