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233 Cards in this Set

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