| Term | Definition |
|---|
| Nursing Process - ADPIE | Assessment, Diagnosis, Plan, Implementation, Evaluation |
| Data Collection - Subjective data | What the pt. or pt's family tells you |
| Data Collection - Objective data | What you as the professional witnesses |
| Methods of Data Collection | Interview with client, Nursing health hx |
| Nursing Health History | Biographical info, present illness or health concerns, family hx (genogram), psycholsocial hx, review of systems, client expectations, health hx, environmental hx, spiritual hx, documentation of findings |
| Medical Diagnosis | clinical judgment about the client in response to an actual or potential health problem. Defined by physician only! |
| Nursing Diagnosis | Identification of a disease condition bases on specific evaluation of signs and symptoms |
| Collaborative Problem | Actual or potential complication that nurses monitor to detect a change in client status |
| Critical Thinking and the Nursing Diagnostic Process | Diagnostic reasoning (acute pain), Clinical criteria (mechanical pain-fx), Defining characteristics (grimacing, crying) |
| Concept Mapping Nursing Diagnosis | A way to graphically represent the connections between concepts and ideas that are related to a central subject such as a client's health problem. Promote problem solving and critical thinking skills by organizing complex client data, analyzing concept relationships and identifying interventions. |
| Nursing Diagnosis - Application of Care Plan | By making accurate nursing diagnosis, care plan will help communicate the client's health care problems to other professionals. Also help you select relevant and appropriate nursing interventions. |
| Nursing Outcomes | 1. pt centered 2. positively stated: will/will not 3. observable + measurable 4. time frame |
| Nursing Interventions | Who will perform intervention, What intervention will take place, When should it take place, Where is the best location to do the intervention, How will you do it? |
| Types of Interventions | Nurse: independant, Physician: dependent, Collaborative: interdependent |
| Expected Outcomes | A specific, measurable change in a client's status. Provide focus or direction. Determines when a specific, client-centered goal has been met. |
| Goal | A broad statement that describes the desired change in a client's condition or behavior. |
| Evaluation Process (5) | 1. Identify evaluative criteria and standards 2. Collect date 3. Interpret and summarize findings 4. Document findings and clinical judgments 5. Terminate, continue, or revise the care plan |
Combine with other sets
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