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35 Cards in this Set
- Front
- Back
actual diagnosis
|
A human response to a health condition or life process that is
happening at the present time. |
|
assessment
|
The systematic and ongoing collection of comprehensive data
relevant to a patient’s health or to the situation or ambience influencing the patient’s health. |
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audit
|
A record or chart review.
|
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baseline data
|
Data taken at the time of the first encounter with the patient.
|
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defining
characteristics |
The manifestations, or signs and symptoms, of a diagnosis.
|
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dependent
interventions |
Nursing interventions that are ordered by a physician or carried out
under a physician’s supervision for the treatment of a medical diagnosis. |
|
diagnosis
|
A clinical judgment about the client’s response to actual or
potential health conditions or needs. |
|
emergency nursing
assessment |
The data collection process that occurs in a life-threatening
situation. |
|
evaluation
|
The process of determining both the client’s progress toward the
attainment of expected outcomes and the effectiveness of nursing care. |
|
focused health
data assessment |
The performance of selected portions of the patient history and
examination process whenever specific conditions warrant this action. |
|
implementation
|
The process of carrying out the plan of care, which may include
any or all of the following activities: providing, monitoring, delegating, coordinating, teaching, and counseling. |
|
independent
interventions |
Nursing interventions that are initiated by the nurse and that
address nursing diagnoses. |
|
Maslow’s
hierarchy of needs |
A tool for prioritizing nursing diagnoses; according to this
hierarchy, a patient’s basic physical needs must be met before his or her safety needs, then social needs, then esteem needs, then selfactualization needs. |
|
nursing
|
The protection, promotion, and optimization of health and
abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations. |
|
nursing process
|
A process for the delivery of nursing care that involves the
following steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. |
|
objective data
|
Signs or observations made directly by the nurse that are capable
of being verified by another person. |
|
outcome
evaluation |
An examination of quality indicators such as number of patient
falls, number of new pressure ulcers formed, number of postoperative wound infections, and number of tube-fed patients developing aspiration pneumonia. |
|
policies
|
Written instructions designed to address a commonly occurring
problem in an institutionally approved manner. |
|
possible diagnosis
|
A diagnosis that is being investigated but has not yet been
confirmed. |
|
primary data
|
Data that the nurse derives directly from interaction with the
patient. |
|
procedures
|
Institutionally approved, preprinted, detailed instructions on how
to perform specific clinical tasks. |
|
process
|
The appropriateness of the care given and whether policies and
procedures were followed to maximize patient safety, minimize medication error, minimize infectious contamination, and ensure that patients and families feel welcome. |
|
protocols
|
Institutionally approved, preprinted instructions governing
interventions or actions to be taken in the care of groups of patients with particular problems. |
|
quality
improvement (QI) |
Methods that focus on diagnosing system problems and suggesting
interventions to address those problems. |
|
risk diagnosis
|
A diagnosis that is likely to occur in a vulnerable person.
|
|
risk factors
|
Those variables that increase a patient’s vulnerability to
developing an actual nursing diagnosis. |
|
secondary data
|
Data derived from sources other than direct interaction with the
patient. |
|
standing orders
|
Institutionally and departmentally approved instructions granting
the nurse the authority to act in the absence of a physician. |
|
state nurse
practice act |
A legal act that regulates the practice of nursing within each state.
|
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structure
|
The setting or the environment in which care is given.
|
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subjective data
|
Data that relies on a conscious patient providing a narrative
statement or report. |
|
syndrome
|
A cluster of diagnoses that are linked to a patient’s condition.
|
|
terminal
evaluation |
Evaluation of patient outcomes prior to discharge of the patient
from the hospital or prior to a case being closed in a community setting. |
|
time-lapsed
nursing assessment |
A repeated assessment obtained to compare data collected at one
or more points in time with baseline data. |
|
wellness diagnosis
|
A human response to achieve an even greater level of wellness.
|