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an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others
knowledge based on research or clinical expertise makes you an informed critical thinker
process of determining a client's health status after you assign meaning to the behaiors, physical signs, and symptoms presented by the client
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
five-step clinical decision-making approach that includes assessment, diagnosis, planning, implementation, and evaluation
the process of purposefully thinking back or recalling a situation to discover its purpose or meaning rewinding a videotape
visual representation of client problems and interventions that shows their relationships to one another
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
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
clinical judgement about individual, family, or community responses to actual and potential health problems or like processes
an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status
clinical criteria or assessment findings that support an actual nursing diagnosis
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
always within the domain of nursing practice and a condition that responds to nursing interventions
ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential
specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
an objective behavior or response that you expect a client to achieve in a short amount of time usually less than a week
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
Dependent nursing interventions
actions that require an order from a physician or another health care provider
therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
trade name for a card-fillinf system that allows quick reference to the needs of the client for certain aspects of nursing care
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
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
physical care technique that you use when a client's physiological or psychological state is threatened
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
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