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233 Cards in this Set
- Front
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Phases of the nursing process:
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assessing; diagnosing; planning; implementing; evaluating - ADPIE
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Thinking that results in the development of new ideas and products.
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Creativity
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The application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas.
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Critical analysis
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(in nursing practice) A discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.
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Critical thinking
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A critical-thinking process for choosing the best actions to meet a desired goal.
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Decision making
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Reasoning from the general premise to the specific conclusion.
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Deductive reasoning
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Generalizations formed from a set of facts or observations.
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Inductive reasoning
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The understanding or learning of things without the conscious use of reasoning.
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Intuition
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A systematic, rational method of planning and providing individualized nursing care.
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Nursing process
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Obtaining information that clarifies the nature of the problem and suggests possible solutions. (trial and error; intuition; research process; scientific method)
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Problem solving
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A technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes.
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Socratic questioning
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Assessing
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The systematic and continuous collection, organization, validation, and documentation of data.
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Cephalocaudal
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or head-to-toe approach begins at the examination of the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes.
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Closed questions
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Used in the directive interview, are restrictive and generally require only "yes" or "no" or short factual answers giving specific information.
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Cues
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Subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, fell, smell, or measure.
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Data
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information
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Database
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All of the information about a client, it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
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Directive interview
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One of two approaches to interviewing; it is highly structured and elicits specific information.
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Inferences
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The nurse's interpretation or conclusions made based on the cues.
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Interview
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Planned communication or conversation with a purpose.
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Leading question
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A question that influences the client to give a particular answer.
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neutral question
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a question that does not direct or pressure a client to answer in a certain way
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nondirective interview
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an interview using open-ended questions and empathetic responses to build rapport and learn client concerns
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objective data
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information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled
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open-ended questions
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questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic
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rapport
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a relationship between two or more people of mutual trust and understanding
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overt data
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see "objective data"
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review of systems
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or screening examination, is a brief review of essential functions of various body parts or systems
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screening examination
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(review of systems) a brief review of essential functions of various body parts or systems
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signs
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see "objective data"
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subjective data
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data that are apparent only to the person affected; can be described or verified only by that person
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symptoms
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see "subjective data"
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validation
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the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data
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Types of assessment
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initial assessment
problem-focused assessment emergency assessment time-lapsed assessment |
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defining characteristics
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client signs and symptoms that must be present to validate a nursing diagnosis
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dependent functions
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with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out
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diagnosis
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a statement or conclusion concerning the nature of some phenomenon
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diagnostic label
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title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association's (NANDA) standardized taxonomy of terms
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etiology
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causal relationship between a problem and its related or risk factors
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independent functions
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an activity that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills
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norm
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an ideal or fixed standard; an expected standard of behavior of group members
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nursing diagnosis
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the nurse's clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
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PES format
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the three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms
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possible nursing diagnosis
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one in which evidence about a health problem is incomplete or unclear
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qualifiers
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words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
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risk factors
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indication that a problem is likely to develop unless nurses intervene
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risk nursing diagnosis
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clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene
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standard
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a generally accepted rule, model, pattern, or measure
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syndrome diagnosis
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a diagnosis that is associated with a cluster of other diagnoses
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taxonomy
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a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles
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wellness diagnosis
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describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement
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assignment
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a downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another
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collaborative care plans
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see "critical pathway"; multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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collaborative interventions
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actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians
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concept map
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a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
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critical pathway
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or "collaborative care plans"; multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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dependent interventions
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those activities carried out on the order of the physician, under the physician's supervision, or according to specified routines
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discharge planning
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the process of anticipating and planning for client needs after discharge
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formal nursing care plan
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a written or computerized guide that organizes information about the client's care
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goals/desired outcomes
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a part of a care plan that describes in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
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independent interventions
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activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills
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indicator
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an observable patient state, behavior, or self-reported perception or evaluation similar to desired outcomes in traditional language
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individualized care plan
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a plan tailored to meet the unique needs of a specific client--needs that are not addressed by the standardized plan
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informal nursing care plan
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a strategy for action that exists in the nurse's mind
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multidisciplinary care plan
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a standardized plan that outlines the care required for clients with common, predictable--usually medical--conditions
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nursing interventions
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any treatments, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
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Nursing Interventions Classification (NIC)
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a taxonomy of nursing interventions developed by the Iowa Intervention Project
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Nursing Outcomes Classification (NOC)
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a taxonomy for describing client outcomes that respond to nursing interventions
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nursing orders
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instructions written on the care plan to direct the specific nursing activities that help the client achieve desired outcomes/goals
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policies
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rules developed to govern the handling of frequently occurring situations
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priority setting
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the process of establishing a preferential order for nursing strategies
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procedures
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steps used in carrying out policies or activities
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protocols
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a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
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rationale
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the scientific reason for selecting a specific action
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standardized care plan
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preprinted guides for giving nursing care of clients with common needs (eg, a nursing diagnosis)
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standing order
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a written document about policies, rules, regulations, or orders regarding client care; give nurses the authority to carry out specific actions under certain circumstances
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audit
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the examination or review of records
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activities
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the specific nursing actions needed to carry out the interventions (or nursing orders)
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cognitive skills
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(intellectual skills) that include problem solving, decision making, critical thinking, and creativity
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concurrent audit
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the evaluation of a client's health care while the client is still receiving care from the agency
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evaluating
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a planned ongoing, purposeful activity in which clients and health care professionals
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evaluation statement
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a statement that consists of two parts: a conclusion and supporting data
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implementing
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the phase of the nursing process in which the nursing care plan is put into action
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interpersonal skills
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all the verbal and nonverbal activities people use when communicating directly with one another
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outcome evaluation
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focuses on demonstrable changes in the client's health status as result of nursing care
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process evaluation
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a component of quality assurance that focuses on how care was given
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quality-assurance program (QA)
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an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
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quality improvement (QI)
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an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI)
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retrospective audit
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the evaluation of a client's record after discharge from an agency
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root cause analysis
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a process for identifying factors that brings about deviations in practices that lead to the event
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sentinel event
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an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
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structure evaluation
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focuses on the setting in which care is given
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technical skills
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hands-on skills such as those required to manipulate equipment, administer injections, and move or reposition patients
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change-of-shift report
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a report given to nurses on the next shift
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chart
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a formal, legal document that provides evidence of a client's care
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charting
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the process of making an entry on a client record
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charting by exception (CBE)
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a documentation system in which only significant findings or exceptions to norms are recorded
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client record
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see "chart"; a formal, legal document that provides evidence of a client's care
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discussion
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an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
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documenting
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see "charting" or "recording"; the process of making an entry on a client record
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flow sheet
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a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form
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focus charting
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a method of charting that uses key words or foci to describe what is happening to the client
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Kardex
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the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date
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narrative charting
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a descriptive record of client data and nursing interventions, written in sentences and paragraphs
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PIE
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an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
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problem-oriented medical record (POMR)
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data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
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problem-oriented record (POR)
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(POR) see "Problem-oriented medical record (POMR)"; data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
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progress note
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chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes
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record
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a written communication providing formal, legal documentation of a client's progress
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recording
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the process of making written entries about a client on the medical record
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report
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whether oral or written, it should be concise, including pertinent information but no extraneous detail
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SOAP
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an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning
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source-oriented record
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a record in which each person or department makes notations in a separate section or sections of the client's chart
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variance
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a goal that is not met; a deviation to what is planned; unexpected occurrences that affect the planned care or the client's response to care
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Purposes of client records:
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communication; planning client care; auditing health agencies; research; education; reimbursement; legal documentation; health care analysis
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documentation systems:
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source-oriented record; problem-oriented medical record; the problems, interventions, evaluation (PIE) model; focus charting; charting by exception (CBE); computerized documentation; case management
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caring
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an essential aspect of nursing
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comfort
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a renewal, an amplification of power or sense of control, an invigorating influence, a positive mind-set, and a readiness for action
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comforting
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a group of nursing interventions based on clients' cues of distress, with the goal of achieving client comfort
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aesthetic knowing
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the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of the client.
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caring practice
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involves connection, mutual recognition, and involvement.
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empirical knowing
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ranges from factual, observable phenomena to theoretical analysis.
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ethical knowing
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focuses on matters of obligation or what ought to be done, and goes beyond simply following the ethical codes of the discipline.
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personal knowing
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promotes wholeness and integrity in the personal encounter, achieves engagement rather than detachment, and denies the manipulative or impersonal approach.
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reflection
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thinking from a critical point of view, analyzing why one acted in a certain way, and assessing the results of one's actions.
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advance health care directives
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includes a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences
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answer
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(legal) a written response made by the defendant
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assault
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an attempt or threat to touch another person unjustifiably
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autopsy
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or "postmortem examination"; an examination of the body after death
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battery
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the willful or negligent touching of a person (or the person's clothes or even something the person is carrying), which may or may not cause harm
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breach of duty
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a standard of care that is expected in the specific situation but that the nurse did not observe; this is the failure to act as a reasonable, prudent nurse under the circumstances
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burden of proof
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the duty of proving an assertion
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causation
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a fact that must be proven that the harm occurred as a direct result of the nurse's failure to follow the standard of care and the nurse could have (or should have) known that failure to follow the standard of care could result in such harm
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civil actions
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deals with the relationship between individuals in society
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civil law
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the body of law that deals with relationships among private individuals; also known as private law
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common law
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the body of principles that evolves from court decisions
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complaint
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(legal) a document filed by the plaintiff
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contract
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a written or verbal agreement between two or more people to do or not do some lawful act
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contract law
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the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreement
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contractual obligations
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duty of care established by the presence of an expressed or implied contract
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contractual relationships
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vary among practice settings; may be as an independent or employer-employee relationship
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coroner
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a public official, not necessarily a physician, appointed or elected to inquire into the causes of death, when appropriate
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credentialing
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the process of determining and maintaining competence in practice; includes licensure, registration, certification, and accreditation
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crime
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an act committed in violation of public (criminal) law and punishable by a fine and/or imprisonment
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criminal actions
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deals with disputes between an individual and the society as a whole
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criminal law
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deals with actions against the safety and welfare of the public
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damages
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if malpractice caused the injury, the nurse is held liable for damages that may be compensated
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decision
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(legal) outcome made by a judge
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defamation
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(legal) a communication that is false, or made with careless disregard for the truth, and results in injury to the reputation of another
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defendants
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(legal) person against whom the plaintiff files a complaint against
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delegation
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transferring to a competent individual the authority to perform a selected nursing task in a selected situation; the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome
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discovery
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(legal) pretrial activities to gain all the facts of the situation
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do not resuscitate (DNR)
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written when the client or proxy has expressed the wish for no resuscitation in the event of respiratory or cardiac arrest
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duty
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the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care
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euthanasia
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the act of painlessly putting to death persons suffering from incurable or distressing disease
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expert witness
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one who has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise
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express consent
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an oral or written agreement
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false imprisonment
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the unlawful restraint or detention of another person against his or her wishes
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felony
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a crime of a serious nature, such as murder, punishable by a term in prison
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foreseeability
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a link that must exist between the nurse's act and the injury suffered
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gross negligence
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involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm
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harm
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the client or plaintiff must demonstrate some type of harm or injury (physical, financial or emotional) as a result of the breach of duty owed the client. The plaintiff will be asked to document physical injury, medical costs, loss of wages, "pain and suffering," and any other damages
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health care proxy
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also referred to as a "durable power of attorney for health care", is a notarized or witnessed statement appointing someone else to manage health care treatment with the client is unable to do so.
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impaired nurse
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a nurse whose practice has deteriorated because of chemical abuse
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implied consent
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consent that is assumed in an emergency when consent cannot be obtained from the client or a relative
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implied contract
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a contract that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist
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informed consent
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a client's agreement to accept a course of treatment or a procedure after receiving complete information, including the risks of treatment and facts relating to it, from the physician
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injury
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see "harm"; the client or plaintiff must demonstrate some type of harm or injury (physical, financial or emotional) as a result of the breach of duty owed the client. The plaintiff will be asked to document physical injury, medical costs, loss of wages, "pain and suffering," and any other damages
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inquest
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a legal inquiry into the cause or manner of death
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interstate compact
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an agreement between two or more states
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invasion of privacy
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a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of reveled information on the standing of the person in the community
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law
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A rule made by humans that regulate social conduct in a formally prescribed and binding manner
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liability
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the quality or state of being legally responsible for one's obligations and actions and to make financial restitution for wrongful acts
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libel
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defamation by means of print, writing, or pictures
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license
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a legal permits granted to individuals to engage in the practice of a profession and to use a particular title
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litigation
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the action of a lawsuit
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living will
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provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions
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malpractice
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the negligent acts of persons engaged in professions or occupations in which highly technical or professional skills are employed
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mandated reporters
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a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities
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manslaughter
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second degree murder
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medical examiner
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a physician and usually has advanced education in pathology or forensic medicine
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misdemeanor
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a legal offense usually punishable by a fine or a short-term jail sentence, or both
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mutual recognition model
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a new regulatory model developed by the National Council of State Boards of Nursing (NCSBN), which allows for multistate licensure
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negligence
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failure to behave in a reasonable and prudent manner; an unintentional tort
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plaintiff
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a person claiming infringement of legal rights by one or more persons
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postmortem examination
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or "autopsy"; an examination of the body after death
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private law
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(civil law) the body of law that deals with relationships between private individuals
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public law
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refers to the body of law that deals with relationships between individuals and the government and governmental agencies
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res ipsa loquitur
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the thing that speaks for itself; a legal doctrine that relates to negligence in which the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act
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respondeat superior
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a legal term meaning "let the master answer"; the employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee
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responsibility
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the obligation associated with a right
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right
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a privilege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily
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slander
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defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a reputation is damaged
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standards of care
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detailed guidelines describing the minimal nursing care that can reasonably be expected to ensure high quality care in a defined situation (eg, a medical diagnosis or a diagnostic test)
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statutory laws
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a law enacted by any legislative body
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strike
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an organized work stoppage by a group of employees to express a grievance, enforce a demand for changes in condition of employment, or solve a dispute with management
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tort
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a civil wrong committed against a person or a person's property
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tort law
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law that defines and enforces duties and rights among private individuals that are not based on contractual agreements
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trial
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the period during which all the relevant facts are presented to a jury or judge
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unprofessional conduct
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one of the grounds for action against the nurse's license; includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using or possessing controlled substances
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verdict
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the outcome made by a jury
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accountability
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being responsible for one's actions and accepting the consequences of one's behavior
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active euthanasia
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actions that directly bring about the client's death with or without consent
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advocate
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individual who pleads the cause of another or argues or plead for a cause or proposal
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assisted suicide
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a form of active euthanasia in which clients are given the means to kill themselves
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attitudes
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mental stance that is composed of many different beliefs; usually involving a positive or negative judgment toward a person, object, or idea
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autonomy
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the right to make one's own decisions
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beliefs
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interpretations or conclusions that one accepts as true
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beneficence
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the moral obligation to do good or to implement actions that benefit clients and their support persons
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bioethics
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ethical rules or principles that govern right conduct concerning life
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code of ethics
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a formal statement of a group's ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions
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consequence-based (teleological) theories
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the ethics of judging whether an action is moral
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ethics
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the rules or principles that govern right conduct
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fidelity
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a moral principle which obligates the individual to be faithful to agreements and responsibilities one has undertaken
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justice
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fairness
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moral development
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process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done; the pattern of change in moral behavior with age
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moral rules
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specific prescriptions for actions
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morality
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a doctrine or system denoting what is right and wrong in conduct, character, or attitude
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nonmaleficence
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the duty to do no harm
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nursing ethics
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ethical issues that occur in nursing practice
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passive euthanasia
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allowing a person to die by withholding or withdrawing measures to maintain life
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personal values
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values internalized from the society or culture in which one lives
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principles-based (deontological) theories
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emphasize individual rights, duties, and obligations
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professional values
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values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers
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relationships-based (caring) theories
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stress courage, generosity, commitment, and the need to nurture and maintain relationships
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responsibility
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the specific accountability or liability associated with the performance of duties of a particular role or an obligation to complete a task
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utilitarianism
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a specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of persons; often used in making decisions about the funding and delivery of health care
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utility
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the principle of utilitarianism
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value set
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all the values (eg, personal, professional, religous) that a person holds
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value system
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the organization of a person's values along a continuum of relative importance
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values
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something of worth; a belief held dearly by a person
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values clarification
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a process by which individuals define their own value
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veracity
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a moral principle that holds that one should tell the truth and not lie
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