Jen ch 15-20 vocab Flashcards
clinical decision making
Problem-solving approach that nurses use to define patient problems and select appropriate treatment.
concept map
Care-planning tool that assists in critical thinking and forming associations between a patient’s nursing diagnoses and interventions.
critical thinking
Active, purposeful, organized, cognitive process used to carefully examine one’s thinking and the thinking of other individuals.
decision making
Process involving critical appraisal of information that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking.
diagnostic reasoning
Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking.
evidence based knowledge
Knowledge that is derived from the integration of best research, clinical expertise, and patient values.
Inference
(1) Judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows.
nursing process
Systematic problem-solving method by which nurses individualize care for each patient. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation..
problem solving
Methodical, systematic approach to explore conditions and develop solutions, including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem.
reflection
Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking.
scientific method
Codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas.
assessment
First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.
back channeling
includes active listening prompts such as “all right,” “go on,” or “uh-huh.” These indicate that you have heard what the patient says and are interested in hearing the full story.
close-ended question
Form of question that limits a respondent’s answer to one or two words.
Concomitant symptoms
any symptom that accompanies a primary symptom.
Cue
Information that a nurse acquires through hearing, visual observations, touch, and smell.
database
Store or bank of information, especially in a form that can be processed by computer.
functional health patterns
Method for organizing assessment data based on the level of patient function in specific areas (e.g., mobility).
nursing health history
Data collected about a patient’s present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness
objective data
Information that can be observed by others; free of feelings, perceptions, prejudices.
open-ended question
Form of question that prompts a respondent to answer in more than one or two words.
Review of Sympotoms (ROS)
a systematic approach for collecting the patient’s self-reported data on all body systems. During the ROS ask the patient about the normal functioning of each body system and any noted changes. Such changes are subjective data because they are described as perceived by the patient. Findings from the ROS are later confirmed during the physical examination.
subjective data
Information gathered from patient statements; the patient’s feelings and perceptions. Not verifiable by another except by inference.
validation
Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.
collabrborative 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
Related signs and symptoms or clusters of data that support the nursing diagnosis.
diagnostic label
name of the nursing diagnosis as approved by NANDA International. It describes the essence of a patient’s response to health conditions in as few words as possible. All NANDA-I approved diagnoses also have a definition. The definition describes the characteristics of the human response identified.
etiology
Study of all factors that may be involved in the development of a disease.
health promotion nursing diagnosis
a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Health promotion diagnoses can be used in any health state and do not require current levels of wellness
medical diagnosis
Formal statement of the disease entity or illness made by the physician or health care provider.
North American Nursing Diagnosis Association (NANDA)
Creates a list which identifies and defines nursing diagnosis
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.
related factor
Any condition or event that accompanies or is linked with the patient’s health care problem.
risk nursing diagnosis
Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
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.
critical pathways
Tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.
dependent nursing interventions
Physician-initiated interventions are dependent nursing interventions, or actions that require an order from a physician or another health care professional. The interventions are based on the physician’s or health care provider’s response to treat or manage a medical diagnosis. Advanced practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions.
expected outcome
a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved. Sometimes several expected outcomes must be met for a single goal.
goal
broad statement that describes a desired change in a patient’s condition or behavior.
independent nursing interventions
actions that a nurse initiates. These do not require an order from another health care professional. As a nurse you act independently on a patient’s behalf. Nurse-initiated interventions are autonomous actions based on scientific rationale.
interdisciplinary care plans
more institutions are developing interdisciplinary care plans which include contributions from all disciplines involved in patient care. The interdisciplinary plan is designed to improve the coordination of all patient therapies and communication among all disciplines.
long term goal
an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (eg: patient will be tobacco free in 60 days)
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-sensitive patient outcome
a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
patient-centered goal
reflects a patient’s highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources
planning
Process of designing interventions to achieve the goals and outcomes of health care delivery
priority setting
the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions
scientific rationale
Reason why a specific nursing action was chosen based on supporting literature.
short-term goal
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
activities of daily living (ADLs)
Activities usually performed in the course of a normal day in the patient’s life such as eating, dressing, bathing, brushing the teeth, or grooming.
adverse reaction
Any harmful, unintended effect of a medication, diagnostic test, or therapeutic intervention.
clinical practice guideline
or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
counseling
Problem-solving method used to help patients recognize and manage stress and enhance interpersonal relationships. It helps patients examine alternatives and decide which choices are most helpful and appropriate.
direct care
treatments performed through interactions with patients
implementation
Initiation and completion of the nursing actions necessary to help the patient achieve health care goals.
indirect care
treatments performed away from the patient but on behalf of the patient or group of patients
instrumental activities of daily living (IADLs)
Activities necessary for independence in society beyond eating, grooming, transferring, and toileting; include such skills as shopping, preparing meals, banking, and taking medications
lifesaving measure
a physical care technique that you use when a patient’s physiological or psychological state is threatened; to restore physiological or psychological homeostasis
nursing intervention
Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. .
patient adherence
patients and families invest time in carrying out required treatments
preventative nursing actions
Nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care.
standing order
Written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings.
evaluation
Determination of the extent to which established patient goals have been achieved.
evaluative measures
assessment skills and techniques (e.g., observations, physiological measurements, patient interview)
standard of care
Minimum level of care accepted to ensure high-quality care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs.
