KEY TERMS Flashcards
Nursing process
Is a systematic method by which nurses plan and provide care for patients
Assessment
A systemic, dynamic way to collect and analyze data about a client
- first step in delivering nursing care
Outcome (goal)
Goals are something that a person strives to achieve
Cue
Is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur
Subjective data
Symptoms and subjective cues
Information that is provided by the patient
- examples: pain, fatigue, and Anxiety
Objective data
Signs and objective cues
Observable and measurable signs
- examples: observe capillary refill, measure patients blood pressure
Primary source
Secondary source
The patient
Family members, significant other, medical record
Biographic data
Provide information about the facts or events in a person’s life
Database
Large store or bank of information
Diagnose
Is to identify the type and cause of a health condition
Nursing diagnosis / patient problem statement
Nanda
Type of health problem that can be identified by the nurse
Defining characteristics
Are the clinical cues, signs, and symptoms that furnish evidence that the problem exists.
Potential patient problems
Two part statements:
1) the patient problem statement with the adjective potential in front of it
2) the risk factors
Collaborative problems
Are health related problems that the nurse anticipates based on the condition or diagnosis of a patient
Medical diagnosis
Is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records and patient history
Goal
The purpose to which an effort is directed
Planning
Developing and modifying a care plan for a patient ,recording relevant information
Nursing interventions
Activities that promote the achievement of desired patient goal
Implementation
The nurse and other members of the team put the established plan into action to promote goal achievement
Evaluation
Is a determination made about the extent to which the established goals have been achieved
Standardized language
Terms that have the same definition and meaning regardless of who uses them
Nursing sensitive patient outcomes
The results or outcomes of nursing interventions
Managed care
Refers to health care systems that have control over primary health care services and attempt to trim down health care costs
Case management
Encompasses planning, coordination of care, and patient advocacy in providing quality
Clinical pathway
Is a multidisciplinary plan that incorporates evidence based practice guidelines for high risk, high volume, high cost types of cases
Variance
If a patient does not achieve the projected outcome
