Chapters 14 & 16 Flashcards
describes the responses to health conditions or life processes that exist in an individual, family or community
Actual Nursing Diagnosis
the collection of data pertinent to the patient’s health status or situation
Assessment
a condition or ethology identified from the patient’s assessment data. It is associated with the patient’s actual or potential response to the health problem and can be changed through the use of nursing interventions.
Related Factor
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
Clinical Criteria
patients’ verbal descriptions of their health concerns
Subjective Data
describes levels of wellness in an individual, family, or community that can be enhanced. A clinical judgement. Transition from a specific level to a higher level
Wellness Nursing Diagnosis
systematic methods for collecting data on all body systems
Review of Systems
describes human response to health conditions or life processes that will possibly develop into a vulnerable individual, family or community
Risk Nursing Diagnosis
an objective behaviour or response that a patient is expected to achieve in a short time, usually less than a week
Short Term Goal
level of quality or attainment
Standards
can be answered stating yes or no
Closed-Ended Questions
an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status
Collaborative Problem
a visual representation that show the connection between a patient’s health problems
Concept Map
involves seeking the expertise of a specialist, such as a nurse educator, registered nurse, or a clinical nurse specialist, to identify ways of approaching and managing the planning and implementation of therapies
Consultation
inter professional treatment plans that outline the treatments or interventions that patients may require for treatment of a condition
Critical Pathways
information that a nurse obtains through use of the senses (e.g. crying)
Cue
another name for a condition
Etiology
the identification of the nature of an illness or other problem by examination of the symptoms
Diagnosis
describes the essence of a patient’s response to health conditions in as few words as possible
Diagnostic Label
assessing the patient’s response to the selected intervention to determine whether the intervention was effective
Evaluation
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then establishing a reasoned conclusion about the patient’s responses to a health problem
Data Analysis
an organized collection of structured information, or data, typically stored electronically in a computer system
Database
the clinical criteria or assessment findings that help confirm an actual nursing diagnosis
Defining Characteristics
specific patient behaviours or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem resolution
Expected Outcomes