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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 data for health problem identification.


active listening technique that prompts a respondent to continue telling a story or describing a situation. (uh-huh, tell me more, go on)

clinical guideline

a document that guides decisions and interventions for specific health care problems or conditions, such as the treatment for a patient who has had a stroke or the administration of chemotherapy.

closed-ended questions

a form of question that limits a respondent's answer to one or two words

collaborative interventions

therapies that require the knowledge, skill, and experience of multiple health care professionals.

collaborative problem

physiological complication that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes.

concept map

a care-planning tool that assists in critical thinking and forming associations between a patient's nursing diagnoses and interventions.


process in which the help of a specialist is sought to identify ways to handle problems in patient management or in the planning and implementing of programs.


a problem-solving method used to help patients recognize and manage stress and to enhance interpersonal relationships; it helps patients examine alternatives and decide which choices are most helpful and appropriate.

critical pathways

tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. designed for a specific care type, a pathway is used to manage the are of a patient throughout a projected length of stay.


information that a nurse acquires through hearing, visual observations, touch and smell.

data analysis

logical examination of and professional judgement about patient assessment data; used in the diagnostic process to derive a nursing diagnosis.

data cluster

a set of signs or symptoms that are grouped together in logical order.


store or bank of information, especially in a form that can be processed by a computer.

defining characteristics

related signs and symptoms or clusters of data that support the nursing diagnosis.

dependent nursing interventions

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

direct care interventions

treatments performed through interaction with the patient. for example: counseling, insertion of iv infusion.


study of all factors that may be involved in the development of disease.


determination of the extent to which established patient goals have been achieved.

expected outcome

expected conditions 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.

functional health patterns

method for organizing assessment data based on the level of patient function in specific areas, for example, mobility.


desired result of nursing actions, set realistically by the nurse and patient as part of the planning stage of the nursing process.

health history

information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations of the health care system.


initiation and completion of the nursing actions necessary to help the patient achieve health care goals.

independent nursing intervention

interventions that nurses initiate on their own to act on a patient's behalf.

indirect care intervention

treatments performed away from the patient but on behalf of the patient or group of patients.


1. a judgement or interpretation of informational cues. 2. taking one proposition as a given and guessing that another proposition follows.

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