Foundations of Nursing V.6 - Ch 6

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32 terms · Chapter 6 - Nursing Process and Critical Thinking Chapter Key Terms in addition to Medical Terminology and relative information.

actual nursing diagnosis

statement of a health problem that a nurse is licensed and competent to treat

assessment

evaluation or appraisal of a condition

biographic data

relating to the fats and events of a person's life

case management

the assignment of a health care provider to oversee the case of an individual patient

clinical pathways

multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high risk, high volume, high cost types of case

collaborative problems

physiologic complication whose treatment requires both nurse and physician prescribed interventions

cue

word, phrase, or symptom that indicates the nature of something perceived

database

large store or bank of information

defining characteristics

clinical signs and symptoms that a problem exists

diagnose

to identify a disease or condition by a scientific evaluation or physical signs, symptoms, history, lab tests and procedures

evaluation

the determination made about the extent to which the established outcomes have been achieved in the nursing care plan

goal

the purpose to which an effort is directed

implementation

the phase of the nursing process that includes ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation

managed care

a health care system that involves administrative control over primary health care services in a medical group practice

medical diagnosis

the identification of a disease or condition by scientific evaluation or physical signs, symptoms, history, lab tests and procedures

NANDA -I

North American Nursing Diagnosis Association - International

nursing diagnosis

a clinical judgement about individual, family, or community responses to actual or high risk health problems or life processes

nursing interventions

activity performed by nurses that should promote the achievement of the desired patient outcome

nursing process

systematic method by which nurses plan and provide care for patients

nursing-sensitive patient outcomes

the results or outcomes of nursing interventions

objective data

of or pertaining to a clinical finding that is observed, palpated, or auscultated

outcome

description of the specific measurable behavior that the patient will be able to exhibit after the nursing intervention

planning

in the 5 step nursing process a category of nursing behavior in which a strategy is designed for the achievement of the goals of care for an individual patient

problem

any health care condition that requires diagnostic, therapeutic, or educational action

risk nursing diagnosis

a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in same or similar situations

standardized language

a structured vocabulary that provides nurses with a common means of communication

subjective data

symptoms, verbal statement provided by the patient

syndrome nursing diagnosis

used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances

variance

the unexpected event that occurs during the use of a clinical pathway

wellness nursing diagnosis

a clinical judgment about an individual, group, community in transition form a specific level of wellness to a higher level of wellness

Nursing Process Chain

Assess, Diagnose, Plan and Outcome, Implement, Evaluate

Maslow's Hierarchy of Needs

Physiologic, Safety and Security, Love and Belonging, Self-esteem, Self-actualization

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