Chapter 6 & 7 Key Terms For Foundations Of Nursing

Front 1

nursing process

Back 1

a systematic method by which nurses plan and provide care for patients

Front 2

assessment

Back 2

a systemic, dynamic process by which the nurse through interaction with the client, sig others, and health care providers, collects and analyzes data about the client

Front 3

Complete assessment

Back 3

a physical examination of all body systems

Front 4

focused assessment

Back 4

information about a specific health problem

Front 5

Types of data

Back 5

subjective

objective

Front 6

sources of data

Back 6

Primary (patient)

secondary (family member)

Front 7

Data clustering

Back 7

assessing all cues

Front 8

Methods of data collecting

Back 8

Interview

Physical exam

Front 9

1st method of data collection

Back 9

Conduct and interview

ask about Biographic data

Front 10

2nd method of data collection

Back 10

physical examination - the physical examination is often guided by subjective data provided by the patient

Front 11

database

Back 11

a large store of bank of information

Front 12

diagnose is

Back 12

to identify the type and cause of a health condition

Front 13

the diagnosis provides

Back 13

the basis for determination of a plan of care to achieve expected outcomes

Front 14

problem

Back 14

any health care condition that requires diagnostic, therapeutic, or educational actions.

Front 15

nursing diagnosis

Back 15

a type of health problem that can be identified

Front 16

components of a nursing diagnosis

Back 16

1. nursing diagnosis title or label

2. definition of title or label

3. contributing, etiologic, or related factors

4. defining characters

Front 17

actual nursing diagnosis

Back 17

actually going on now

Front 18

risk nursing diagnosis

Back 18

no symptoms just at risk for it

Front 19

syndrome nursing diagnosis

Back 19

used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances

Front 20

wellness nursing diagnosis

Back 20

human responses to levels of wellness in an individual, family, or community

Front 21

example of a wellness nursing diagnosis

Back 21

readiness for enhanced decision making

Front 22

Medical diagnosis

Back 22

made only by a doctor; the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test, and procedures

Front 23

goal

Back 23

statement is a statement about the purpose to which an effort is directed

Front 24

outcome

Back 24

states the behaviors that the patient will be able to perform rather than what the nurse will do

Front 25

planning

Back 25

establish priorities of care

Front 26

nursing interventions

Back 26

are those activities hat promote the achievement of the desired patient outcome

Front 27

physician-prescribed interventions

Back 27

actions ordered by a physician for a nurse or other health care professional to perform

Front 28

nurse-prescribed interventions

Back 28

actions that a nurse is legally able to order or begin independently

Front 29

nursing orders include:

Back 29

*Date

*Sig of nurse responsible for the care plan

*Action verb

*Qualifying details

Front 30

Implenentation

Back 30

putting a plan into action to promote outcome achievement

Front 31

CPR

Back 31

cardiopulmonary resuscitation

Front 32

which intervention is best used?

Back 32

the one that will have the best impact on patient outcomes

Front 33

Evaluaton

Back 33

a determination made about the extent to which the established outcomes have been achieved

Front 34

steps of evaluation

Back 34

1. Review

2. Reassess

3. Compare

Front 35

Standardized language

Back 35

one in which terms are carefully defined and mean the same thing to all who use them

Front 36

LPN/LVN

Back 36

is responsible for providing direct bedside nursing care

Front 37

managed care

Back 37

a health care system that provides control over health care services for a specific group of individuals in attempts to control cost

Front 38

case management

Back 38

refers to the assignment of a health care provider to a patient so that the care of that patient is overseen by one individual

Front 39

clinical pathway

Back 39

a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, high-cost types of cases

Front 40

variance

Back 40

exit

Front 41

critical thinking

Back 41

a complex process, and no single simple definition explains all aspects of critical thinking

Front 42

chart (health care record)

Back 42

its a legal record that is used to meet the many demands of the health, accreditation, medcal insurance and legal system

Front 43

the process of adding writing information to the chart is called

Back 43

charting, recording, or documentaton

Front 44

documenting involves

Back 44

recording the interventions carried out to meet the patients needs

Front 45

good documenting reflects

Back 45

the nursing process

Front 46

purposes for accurate and complete written patient records

Back 46

1. written communication

2. permanent record for accountability

3. legal record of care

4. teaching

5. research and data collection

Front 47

auditors

Back 47

people appointed to examine patients charts and health record to assess quality of care

Front 48

peer review system

Back 48

appraised by professional co-workers of equal status

Front 49

diagnosis-related groups (DRGs)

Back 49

a system that classifies patients by age, diagnosis, and surgical procedure, using 300 different categories to predict the use of hospital resources, including length of stay

Front 50

nursing notes

Back 50

the form on the patients chart on which nurses record their observations, the care given, and the patients response

Front 51

traditional (block) chart

Back 51

divided into sections or blocks

Front 52

narrative charting

Back 52

recording of patient care in descriptive form

Front 53

SOAPIER

Back 53

Subjective info

Objective info

Assessment

Plan

Intervention

Evaluation

Revision

Front 54

SOAPE

Back 54

Subjective info

Objective info

Assessment

Plan

Evaluation

Front 55

focus charting format

Back 55

Data

Action

Response & evaluation

Education & patient teaching

Front 56

PIE

Back 56

problem intervention and evaluation

Front 57

Kardex (or Rand) system

Back 57

a card system used to consolidate patent orders and care needs in a centralized concise way

Front 58

Acuity charting

Back 58

uses a score that rates each patent by severity of illness

Front 59

nursing time is spent

Back 59

50% documenting

Front 60

(conventions) nomenclature

Back 60

a classified system of technical or scientific names and terminology

Front 61

key points of documentation

Back 61

1. write legible

2. approved abbreviations

3. no opinions - ONLY FACTS

4. time/date/signature

5. use ink

Front 62

chart for who?

Back 62

only yourself