Assessment
Deliberate and systematic collection of data about a patient. First step of the nursing process; activities required in the first step are data collection, data validation, data sorting, and data documentation. The purpose is to gather information for hea
Back-Channeling
The practice of giving positive comments such as "all right," "go on," or "uh-huh" to the speaker. These indicate you have heard what the patient says and are attentive to hear the full story. Active listening technique
Clinical Guideline
A document that guides decisions and interventions for specific health care problems or conditions, such as treatment for a patient who has had a stroke or the administration of chemotherapy. Ideally the guideline or protocol is developed on the basis of
Closed-Ended Questions
Limit the patient's answers to one or two words such as "yes" or "no" or a number or frequency of a symptom.
Collaborative Interventions
Interdependent nursing interventions, are therapies that require the combined knowledge, skills, and expertise of multiple health care professionals.
Collaborative Problem
An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. Require the nurse to use nursing-prescribed and physician prescribed interventions to maximize patient outcomes.
Concept Map
A care-planning tool that assist in critical thinking and for ming associations between a patient's nursing diagnoses and interventions. Provides a visual representation of your pateint's medical problems, nursing assessment data, nursing diagnoses, and t
Consultation
Process in which you seek the expertise of a specialist, such as your nursing instructor or a clinical nurse specialist, to identify ways to handle problems in patient care management or in the planning and implementation of therapies.
Counseling
Direct care method that helps patients use a problem-solving process to recognize and manage stress andto facilitate interpersonal relationships. Involves emotional, intellectual, spiritual, and psychological support. Examples are behavior modification, b
Critical Pathways
Patient care management plans that provide the multidisciplinary health team with the activities and tasks to be put into practice sequentially; their main purpose is to deliver timely care at each phase of the care process for a specific type of patient.
Cue
Information you obtain through the use of your senses.
Data Analysis
Involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to reasoned conclusion about the patients' response to a health problem.
Data Cluster
A set of signs or symptoms that are grouped together in logical order.
Database
Store or bank of information.
Defining Characteristics
The clinical criteria or assessment findings that support an actual nursing diagnosis. Related signs and symptoms or clusters of data
Dependent Nursing Intervention
Physician-initiated intervention. Actions that require an order from a physician or another health care provider.
Direct Care Interventions
Treatments performed through interactions with patients. Examples are medication administration, insertion of an intravenous catheter, and counseling during a time of grief.
Etiology
Study of all factors that may be involved in the development of a disease.
Evaluation
Crucial to deciding whether, after interventions have been delivered, a patient's condition or well-being improves. Determination of the extent to which established patient goals have been met.
Expected Outcome
Expected coditions of a patient at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education. Observable effects (change in a patient's physical condition
Functional Health Patterns
Method for organizing assessment data based on the level of patient function in specific areas, for example, mobility.
Goals
Desired result of nursing actions, set realistically by the nurse and patient as part of the planning stage of the nursing process. Contains singular behaviors or responses. Establishes a time frame, there are short-term and long-term.
Health History
Includes information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system.
Implementation
The performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care
Independent Nursing Interventions
Nurse-initiated interventions. The nurse initiates on their own to act on a patients' behalf. These do not require direction or an order from another health care professional. Examples include elevating an edematous extremity, offering counseling on copin
Indirect Care Interventions
Treatments performed away from the patient but on behalf of the patient or group of patients. Examples are action aimed at managing the patient's environment (safety and infection control), documentation, and interdisciplinary collaboration.
Inference
Your judgment or interpretation of cues.
Instrumental Activities of Daily Living (IADL's)
Skills such as shopping, preparing meals, writing checks, and taking medications. Nurses in home care and community nursing frequently assist patients in adapting ways perform these activities.
Interdisciplinary Care Plans
Includes contributions from all disciplines involved in patient care. Improves the coordination of all patient therapies.
Medical Diagnosis
The identification of a disease condition based on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures.
NANDA (NANDA)
The North American Diagnosis Association, established in 1982 with the follwing purpose: "To develop, refine, and promote a taxonomy of nursing diagnostic terms of general use for professional nurses." Intent to create a common language for nurses to be a
Nursing Diagnostic Process
Flows from the assessment process and includes data clustering, interpretation and analysis, identifying patient needs, and formulating the nursing diagnosis or colaborative problem.
Nursing-Sensitive Outcomes
Measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions.
Objective Data
Observations or measurements of a patient's health. Inspection of the condition of a wound or observation of a patient's posture and gait are examples of.
Open-Ended Questions
Prompts patients to describe a situation in more than one or two words. This technique leads to a discussion in which the patients actively describe their health status.
Planning
Involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.
Related Factors
Condition or etiologic factor that appears to show some type of patterned relationship with the nursing diagnosis.
Scientific Rationale
The reason for the interventions.
Standard of Care
Minimum level of care accepted to ensure high quality care to patients. They define the types of therapies typically administered to patiens with specific problems or needs.
Standing Order
Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/ or diagnostic procedures for specific patients with identified clinical problems.
Subjective Data
Patint's verbal descriptions of thier health problems.
Validation
The comparison of data with another source to confirm their accuracy.
3 Phases of an Interview
Orentation, Working, and Termination
5 Types of Nursing Diagnosis
Actual, HealthPromotion, Risk, Syndromes, and Wellness
(ADL's)
Ativities usually performed during a normal day; including ambulation, eating, dressing, bathing, and grooming. A patient's need for assistance with ADL's may be temporary, as in the case of an active illness, or permanent.
3 Implemenatation Skils
Cognitive, Interpersonal, and Psycomotor
5 Elements in the Evaluation Process
1.) Identifying evaluative criteria and standards
2.) collecting data to determine if you met the criteria or standards
3.) interpreting and summarizing findings
4.) documenting findings
5.)terminating, continuing, or revising the plan
3 Critical Thinking Competencies in Nursing
1.) General critical thinking
2.) Specific critical thinking in clinical situations
3.) Specific critical thinking in nursing
Nursing Process
Professional nurse's approach to identifying, diagnosing, and treating human responses to health and illness.
Nursing Diagnosis
Clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. Provides the basis selection of nursing interventions to achieve outcome for which the nurse is accountable.
Nursing Intervention
Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes.
5 Step Nursing Process
Assessment, Nursing Diagnosis, Planning, Implementation, and Evaluation
Data Documentation and Communication
Communication of assessment findings, either verbally or through documentation, is the last step of a complete assessment. Observation, reporting, and recording of a patient's status is a legal and professional responsibility.
Risk Factors
Environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerabilty of an individual, family, or community to an unhealthy event. Cues to indicate that a risk nursing diagnosis applies to a patient's condition.
Patient-Centered Goal
Specific and measurable behavoir or response that reflects the patient's highest possible level of wellness and independence in function. A patient goal represents predicted resolution of a problem, evidence of progress toward problem resolution, progress