Nursing Process Key Terms Flashcards
thought that is disciplined, comprehensive, based on intellectual standards, and well-reasoned
a systemic way to form and shape thoughts that functions purposefully and exactingly
Critical Thinking
ways of thinking about patient care issues
determining, preventing, and managing patient problems
Clinical Reasoning
refers to result of critical thinking or clinical reasoning
conclusion/decision a nurse makes
Clinical Judgment
between caregiver and patient that is focused on promoting or restoring health and well-being of the patient
Therapeutic Relationships
care of patient by clinician who utilizes clinical reasoning and reflective practice to guide
Thoughtful Practice
model of patient care based on holistic roots in which nurse uses every clinical encounter to assess how patient is doing and communicating respect, care, and compassion
Person-Centered Care
direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible
Intuitive Problem Solving
5-step systematic process for giving patient care
assessing, diagnosing, planning, implementing, evaluting
Nursing Process
to systematically and continuously collect, validate, and communicate patient data
Assessing
significant info that is helpful in making decisions
Cue
judgment reached about a cue
Inference
comes from the patient or the patient’s family
abstract data like symptoms (pain)
Subjective Data
can be measured
vital signs, inspection, palpation, etc
Objective Data
assess a specific problem
Focused Assessment
rapid focused assessment conducted when addressing a life-threatening or unstable situation
Emergency Assessment
scheduled exam to compare patient’s current status to baseline data obtained earlier
Time-Lapsed Assessment
comprehensive nursing assessment resulting in baseline data
Initial Assessment
conscious and deliberate use of 5 senses to gather data
Observation
act of confirming/verifying
Validation
analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
Diagnosing
actual or potential health problem that independent nursing interventions can prevent or resolve
defining characteristics are present as risk factors
Nursing Diagnosis
statement about a specific disease process using terminology from a well-developed classification system accepted by medical profession
Medical Diagnosis
acceptable, expected level of performance established by authority, custom or consent
Standard
grouping of patient data or cues that points to existence of patient health problem
Data Cluster
specific, measurable criteria used to evaluate whether the patient goal has been met
Expected Outcome
an aim or an end
Goal
establish patient goals to prevent, reduce, or resolve the problems identified in nursing diagnoses and determination of related nursing interventions
Planning
observation of patient to demonstrate resolution of problems identified by nursing diagnoses and general problem list, along w/ time frame for accomplished these outcomes
Outcome Identification
written guide to direct the efforts of the nursing team as they work with the patient to meet health goals
specifies prioritized nursing diagnoses, patient goals, and nursing orders
Nursing Care Plan
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes
there are nurse-initiated, physician-initiated, and collaborative interventions
Nursing Intervention
specified behavior
Criteria
carry out the plan of care
Implementing
transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome
Delegation
individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse
Unlicensed Assistive Personnel (UAPs)
ongoing process of questioning and evaluating practice and advancing informed practice
Clinical Inquiry
document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present
may expand scope of nursing responsibilities
Standing Orders
written plan that details the nursing care to be implemented in specific situations
Protocols
measurement of extent to which patient has achieved goals specified in plan of care
Evaluating
rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurses, the patient, and the institution where health care is given
Standards
judgment summarizing nurse’s findings after data have been collected and interpreted to determine patient outcome achievement
Evaluative Statement
objective and subjective data
Assessment
priority problem
could be actual or potential problem
Diagnosis
Goals/Outcomes
prioritizing long term and short term goals
Maslow’s Heirarchy of Needs
ABCs - Airway, Breathing, Circulation
Plan
Take Action!
complex - teaching plans
simple - raise head of bed
Intervention
Was the intervention successful?
- Did they improve?
- Did they remain the same?
- Did they decline?
Evaluation
