48 terms

Module 15 Nursing Process

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
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
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
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
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
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
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
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