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