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Foundation of Nursing 1 Terms > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

blended competencies

A

set of intellectual, interpersonal, technical, and ethical/legal capacities needed for professional nursing

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2
Q

clinical judgment

A

result of critical thinking or clinical reasoning

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3
Q

clinical reasoning

A

referring to ways of thinking about patient care issues, reasoning about clinical issues

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4
Q

creative thinking

A

involves imagination, intuition, and spontaneity

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5
Q

critical thinking

A

thoughts that are disciplined, comprehensive, and based on intellectual standards

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6
Q

decision making

A

goal-directed effort applied in a systematic way to make a choice

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7
Q

intuitive problem solving

A

direct understanding of a situation based on a background of experience, knowledge, and skill

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8
Q

nursing process

A

5 step method of giving patient care

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9
Q

person-centered care

A

Based on holistic roots, every clinical encounter is used to assess how the person is doing

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10
Q

Quality and safety education for nurses (QSEN)

A

Prepares future nurses with the knowledge, skills, and attitudes (KSA) necessary to improve the healthcare system

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11
Q

reflective practice

A

caregiver has a profound awareness of self and own biases, understand how they may affect the therapeutic relationship

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12
Q

scientific problem solving (7 steps)

A

Problem identification, data collection, hypothesis formulation, plan of action, hypothesis testing, interpretation of results, evaluation

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13
Q

thoughtful practice

A

care of a patient by a caregiver who uses clinical reasoning and reflective practice to guide thoughtful actions and person-centered care

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14
Q

trial and error problem solving

A

involves testing any number of solution until one is found that works for that problem

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15
Q

assessing

A

systematically and continuously collect, validate and communicate patient data

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16
Q

cue

A

significant information that is helpful for decision making

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17
Q

database

A

all pertinent patient info that enables a effective plan of care

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18
Q

focused assessment

A

assess specific problem or highest priority concerns

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19
Q

inference

A

judgment reached about a cue

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20
Q

initial assessment

A

comprehensive assessment, baseline data to make judgments about health status, need for nursing and to plain individualized care

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21
Q

interview

A

planned communication for a specific purpose

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22
Q

minimum data set

A

specifies the info that must be collected from every patient

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23
Q

nursing history

A

identify patient’s health status, strengths, health problems, health risks, and need for nursing care

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24
Q

objective data

A

perceptible to the sense, verified by another person

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25
observation
conscious and deliberate use of the five senses to gather data
26
patient-centered assessment method (PCAM)
assesses patient complexity using the social determinants of health
27
physical assessment
objective, better defines patient's condition and helps plan care
28
Review of systems (ROS)
physical examination of all body systems
29
subjective data
info perceived only by the affected person
30
collaborative problem
health problem that may occur from complications of disease or treatment. nurse works with other members of the health care team
31
data cluster
grouping of patient data or cues that point to the existence of a health problem
32
diagnosing
analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
33
diagnostic error
failure to detect an actual unhealth behavior or condition
34
health problem
condition related to health requiring intervention if disease or illness is to be prevented or resolved
35
health promotion nursing diagnosis
behavior of an individual motivated by a personal desire to increase well-being and health potential
36
medical diagnosis
statement about a specific disease process using terminology from a well-developed classification system
37
nursing diagnosis
actual or potential health problem that an independent nursing intervention can prevent or resolve, characteristics are present as risk factors
38
risk nursing diagnosis
clinical judgments that an individual or community is more vulnerable to develop the problem than others in the same situation
39
syndrome
cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation
40
clinical or critical pathways (CareMaps)
Case management tools used to communicate the standardized plan of care for a particular group of patients
41
collaborative interventions
interdependent nursing actions performed jointly by nurses and other members
42
computerized plans of nursing care
plans of patient care developed by computers that enable nurses to use plans for diagnoses
43
criteria
specified behavior, measurable criteria
44
discharge planning
preparing the patient to leave the healthcare facility
45
initial planning
addresses each problem in the nursing diagnoses and identifies patient goals
46
nurse initiated intervention
independent nursing actions that involve carrying out nurse prescribed interventions or interventions based on patient needs
47
nursing intervention
any treatment based on clinical judgment and knowledge, performed to enhance patient outcomes
48
Nursing interventions classification (NIC)
list of nursing interventions applicable to all settings that can be used by nurses
49
Nursing outcomes classification (NOC)
presents comprehensive standardized language used to describe patient outcomes that relate to intervention
50
ongoing planning
carried out by any nurse who interacts with the patient, keeps plan up to date, manage risk factors
51
outcome identifcation
patient demonstrating resolution of the problems identified, has a time frame
52
patient outcome
expected conclusion to health problem
53
physician-initiated intervention
dependent nursing actions, carrying out physician prescribed orders
54
planning
establish patient goals to prevent, reduce, or resolve, the problems identified in the nursing diagnoses and determination of related nursing interventions
55
standardized care plans
prepared plan of care for a specific population or problem
56
clinical inquiry
ongoing process of questioning and evaluating practice and advancing informed practice
57
delegation
transfer of responsibility, still have accountability for the outcome
58
direct care intervention
treatment performed through interaction with the patient
59
evidence-based practice
nursing care provided that is supported by scientific rationale
60
implementing
carry out the plan of care
61
indirect care interventions
treatment performed away from the patient but on behalf of the patient
62
protocols
written plan that details the nursing activities to be executed in certain situations
63
standing orders
document that details the nursing care to be implemented in specific nursing situations
64
unlicensed assistive personnel (UAP)
trained to function in an assistive role to the RN, is delegated
65
concurrent evaluation
evaluation of nursing care and patient outcomes while the patient is receiving care
66
evaluating
measurement of the extent to which the patient has achieved the goals specified in the plan of care, identify negative and positive factors that influence goals
67
evaluative statement
judgment summarizing the nurse's findings after data has been collected and interpreted
68
National database of nursing quality indicators (NDNQI)
Database of nursing sensitive quality indicators aimed at promoting and facilitating the standardization of info
69
nursing sensitive quality indicators
identify structures of care and care processes that influence care outcome
70
outcome evaluation
focuses on measurable changes in the health status of the patient or end results of nursing care
71
performance improvement
commitment to healthier patients, making a difference, reduce costs, planning a strategy, implementing a change, and assessing the change to see if the goal is met
72
process evaluation
focusing on the nature and sequence of activities carried out by nurses implementing the nursing process
73
quality assurance program
ongoing evaluation of excellence of health care, may assess structure, process, and outcome standards
74
quality improvement (QI)
commitment and approach used to improve every process in every part of an organization. means to met and exceed expectations and outcomes
75
retrospective evaluation
evaluation of nursing care and patient outcomes after patient has been discharged
76
standards
rules that allow nurses to carry out professional roles
77
structure evaluation
focuses on the environment in which care is provided, an audit

Foundation of Nursing 1 Terms (16 decks)

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