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Critical Thinking

an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others

Evidence-Based Knowledge

knowledge based on research or clinical expertise makes you an informed critical thinker

Problem Solving

involves evaluating the solution over time to make sure that it is effective

Decision Making

product of critical thinking that focuses on problem resolution

Diagnostic Reasoning

process of determining a client's health status after you assign meaning to the behaiors, physical signs, and symptoms presented by the client

Inference

process of drawing conclusions from related pieces of evidence

Clinical Decision Making

requires careful reasoning so that you choose the options for the best client outcomes on the basis of the client's condition and the priority of the problem

Prognosis

diagnosed problem

Nursing process

five-step clinical decision-making approach that includes assessment, diagnosis, planning, implementation, and evaluation

Standards of practice

minimum level of performance accepted to ensure high-quality care

Reflection

the process of purposefully thinking back or recalling a situation to discover its purpose or meaning rewinding a videotape

Concept Map

visual representation of client problems and interventions that shows their relationships to one another

Assessment

includes subjective and objective data

Subjective Data

client's verbal descriptions of their health problems

Objective Data

obervations or measurements of a client's health status

Interview

an organized conversation with the client

Nursing Health History

includes data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness

Medical Diagnosis

the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's med history and the results of diagnostic tests and procedures

Nursing Diagnosis

clinical judgement about individual, family, or community responses to actual and potential health problems or like processes

Collaborative Problem

an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status

Defining Characteristics

clinical criteria or assessment findings that support an actual nursing diagnosis

Clinical Criteria

objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion

Actual Nursing Diagnosis

describes human responses to health conditions or life processes that exist in an individual fam or community

Risk Nursing Diagnosis

describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, fam, or community

Health Promotion Nursing Diagnosis

clinical judgment of a person's, family's, or community;s motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific behaviors such as nutrition and exercise

Wellness nursing diagnosis

describes human responses to levels of wellness in an individual, family, or community that have readiness for enhancement

Diagnostic Label

name of the nursing diagnosis as approved by NANDA

Related Factor

condition or etiology identified from the client's assessment data

Etiology

always within the domain of nursing practice and a condition that responds to nursing interventions

Priority setting

ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential

Client-centered goal

specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function

Short-term goal

an objective behavior or response that you expect a client to achieve in a short amount of time usually less than a week

Long-term goal

an objective behavior or response that you expect a client to acheive over a longer period, usually over several days, weeks, or month.

Nursing-Sensitive client outcome

individual, family, or community state, behavior, or perception that is measurable along continuum

Independent nursing interventions

actions that a nurse initiates

Dependent nursing interventions

actions that require an order from a physician or another health care provider

Collaborative intervention

therapies that require the combined knowledge, skill, and expertise of multiple health care professionals

Nursing Care plan

lists specific nursing interventions needed to achieve the goals of care

Scientific rationale

reason that you chose a specific nursing action, based on supporting evidence

Kardex

trade name for a card-fillinf system that allows quick reference to the needs of the client for certain aspects of nursing care

Critical Pathways

multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition

Indirect Care

treatments performed away from the client but on behalf of the client or group of clients

Activities of daily living

activities usually performed in the course of a normal day including ambulation, eating, dressing, bathing, brushing the teeth, and grooming

Instrumental Activities of daily living

shopping, preparing meals, wrting checks, taking meds

Lifesaving Measure

physical care technique that you use when a client's physiological or psychological state is threatened

Adverse reaction

harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention

Preventive Nursing Action

promote health and prevent illness to avoid the need for acute or rehabilitative health care

Interdisciplinary care plan

plans representing the contributions of all disciplines caring for a client

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