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47 Cards in this Set

  • Front
  • Back
Clinical Decision Making p. 196
problem solving approach that nurses use to define patient problems and select appropriate treatment
Concept Map p. 202
care planning tool that assists in critical thinking and forming associations between a patient's nursing diagnosis and interventions
Critical Thinking p. 193
active, purposeful, organized, cognitive process used to carefully examine one's thinking and the thinking of other individuals
Decision Making p. 195
process involving critical appraisal of information that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion; comes at the end of critical thinking
Diagnostic Reasoning p. 196
process that enables am observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking
Evidence-based Knowledge p. 193
knowledge that is derived from the integration of best research, clinical expertise, and patient values
Inference p. 196
judgment or interpretation of informational cues; taking one proposition as a given and guessing that another proposition follows
Nursing Process p. 197
systematic problem solving method by which nurses individualize care for each patient; five steps of nursing process are assessment, diagnosis, planning, implementation, evaluation
Problem Solving p. 195
methodical, systematic approach to explore conditions and develop solutions, including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem
Reflection p. 202
process of thinking back or recalling an event to discover the meaning and purpose of that event; useful in critical thinking
Scientific Method p. 195
codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas
Assessment p. 207
first step of the nursing process; activities required in the first step are data collection, validation, sorting and documentation.
the purpose is to gather info for health problem identification
Close-ended Questions p. 214
form of question that limits a respondent's answer to one out two words
Cue p. 208
information that a nurse acquires through hearing, visual observations, touch, and smell
Database p. 207
store or bank of information, especially in a form that can be processed by computer
Functional Health Patterns p. 208
method for organizing assessment data based on the level of patient function in specific areas
Inference p. 208
judgment or interpretation of informational cues
Nursing Health History p. 214
data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to health
Nursing Process p. 206
problem solving method; assessment, diagnosis, planning, implementation, and evaluation
Objective Data p. 210
information that can be observed by others; free of feelings, perceptions, prejudices
Open-ended Questions p. 213
form of question that prompts a respondent to answer in more than one or two words
Subjective Data p. 210
information gathered from patient statements; there patient's feelings and perceptions.
not verifiable by another except by inference
Validation p. 217
act of confirming, verifying, it corroborating the accuracy of assessment data or the appropriateness of the care plan
Actual Nursing Diagnosis p. 227
judgment that is clinically validated by the presence of major defining characteristics
Collaborative Problem p. 222
physiological complication that requires the nurse to use nursing and health care provider prescribed interventions to maximize patient outcomes
Data Cluster p. 226
set of signs or symptoms that are grouped together in logical order
Defining Characteristics p. 226
related signs and symptoms or clusters of data that support the nursing diagnosis
Etiology p. 229
study of all factors that may be involved in the development of a disease
Medical Diagnosis p. 222
formal statement of the disease entity or illness made by the physician or health care provider
Nursing Diagnosis p. 222
formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step of the nursing process, during which the patient's actual and potential unhealthy responses to an illness or condition are identified
Related Factor p. 227
any condition or event that accompanies or is linked with the patient's health care problem
Risk Nursing Diagnosis p. 228
describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community
Collaborative Interventions p. 242
therapies that require the knowledge, skill, and expertise of multiple health care professionals
Consultation p. 249
process in which the help of a specialist is sought to identify ways to handle problems in patient management or in planning and implementing programs
Critical Pathways p. 247
tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for patient.
designed for a specific case type, a pathway is used to manage the care of a patient throughout a projected length of stay
Planning p. 236
process of designing interventions to achieve the goals and outcomes of health care delivery
Scientific Rationale p. 245
reason why a specific nursing action was chosen based on supporting literature
Activities of Daily Living (ADLs) p. 259
activities usually performed in the course of a normal day in the patient's life such as eating, dressing, bathing, brushing the teeth, or grooming
Adverse Reaction p. 261
any harmful, unintended effect of a medication, diagnostic test, or therapeutic intervention
Counseling p. 260
problem solving method used to help patients recognize and manage stress and enhance interpersonal relationships; it helps patients examine alternatives and decide which choices are most helpful and appropriate
Implementation p. 253
initiation and completion of the nursing actions necessary to help the patient achieve health care goals
Instrumental Activities of Daily Living (IADLs) p. 260
activities necessary for independence in society beyond eating, grooming, transferring, and toileting; include such skills as shopping, preparing meals, banking, and taking medications
Nursing Intervention p. 253
any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
Preventive Nursing Actions p. 261
nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care
Standing Order p. 256
written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care and various stipulated clinical settings
Evaluation p. 265
determination of the extent to which established patient goals have been achieved
Standard of Care p. 271
minimum level of care accepted to ensure high quality care to patients; standards of care define the types of therapies typically administered to patients with defined problems or needs