Funda

Front 1

reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.

Back 1

Critical thinking

Front 2

application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas.

Back 2

Critical analysis

Front 3

technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate one knows from what one merely believes.

Back 3

Socratic questioning

Front 4

Generalizations are formed from a set of facts or observations.

Back 4

Inductive

Front 5

reasoning from general premise to the specific conclusion.

Back 5

Deductive

Front 6

systemic, rational method of planning and providing individualized nursing care.

Back 6

Nursing process

Front 7

Approaches to problem solving:

Back 7

Trial and error

Intuition

Research process and scientific/modified scientific method

Front 8

number of approaches are tried until a solution is found.

Back 8

Tae

Front 9

nursing, this method can be dangerous because the client might suffer harm if an approach is inappropriate.

Back 9

Tae

Front 10

understanding or learning of things without the conscious use of reasoning.

Back 10

Intuition

Front 11

also known as “sixth sense, hunch, instinct, GUT feeling, or suspicion. The nurse must first have the knowledge and experience.Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions.Not recommended for novices or students.

Back 11

Intuition

Front 12

formalized, logical, systematic approach to solving problems.

Back 12

Research process

Front 13

critical-thinking process for choosing the best actions to meet a desired goal.

Back 13

Decision making

Front 14

Is a systematic, rational method of planning and providing Nsg.Care

Back 14

Nursing process

Front 15

Baseline for evaluation of careIs a continuous process carried out during all phases of the nursing process.The BASIS (BASELINE) of all the succeeding phases

Back 15

Assessment

Front 16

Assessment activities

Back 16

Collecting & Establishing data

Validating data -

Organizing data -

Documenting

Front 17

Performed within specified time after admission to a health care agency

Back 17

Initial a

Front 18

Ongoing process integrated with nursing care

determine the status of a specific problem identified in an earlier assessment

Back 18

Problem focused a

Front 19

During any physiologic or psychological crisis of the client

Back 19

Emergency

Front 20

To compare the client’s current status to baseline data previously obtained

Back 20

Time lapsed

Front 21

process of gathering information about a client’s health status.

Back 21

Collecting data

Front 22

occurs whenever the nurse is in contact with the client

Back 22

Observing

Front 23

used mainly while taking the nursing health history

Back 23

Interviewing

Front 24

major method used in the physical health assessment.

Back 24

Examining

Front 25

highly structured and elicits specific information.

nurse establishes the purpose of the interview and controls the interview, at least at the outset.RN uses CLOSE-ended questions

Back 25

Directive interview

Front 26

nurse allows the client to control the purpose, subject matter, and pacing.

Back 26

Nondirective interview

Front 27

Is a systematic data-collection method that uses observation and inspection, auscultation, palpation, and percussion

Back 27

Examining

Front 28

begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes.

Back 28

Cephalocaudal

Front 29

Investigates each system individually, that is, the respiratory system, the circulatory system, the nervous system, and so on.

Back 29

Body systems approach

Front 30

brief review of essential functioning of various body parts or systems.

Back 30

Screening examination

Front 31

assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence levels of wellness.

Back 31

Wellness model

Front 32

double-checking” or verifying data to confirm that it is accurate and factual.

Back 32

Validation

Front 33

subjective or objective data that can be directly observed by the nurse.

Back 33

Cues

Front 34

the nurse’s interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot, and swollen; the nurse makes the inference that the incision is infected.

Back 34

Inferences

Front 35

classification system or set of categories arranged based on a single principle or set of principles.

Back 35

Taxonomy

Front 36

reasoning process

Back 36

Diagnosing

Front 37

statement or conclusion regarding the nature of a phenomenon.

Back 37

Diagnosis

Front 38

…is a clinical judgment about individual, family, or community responses to actual, and potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

Back 38

Nursing Diagnosis

Front 39

Client problem that is present at the time of the nursing assessment

Back 39

Actual

Front 40

Clinical judgment that a problem does not exist but Presence of risk factors indicates that a problem is LIKELY TO DEVELOP unless nurses intervene

Back 40

Risk Diagnosis

Front 41

describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement”

Back 41

Wellness dx

Front 42

Evidence about a health problem is incomplete or unclear Requires more data to either support or to refute it

Back 42

Possible dx

Front 43

Associated with a cluster of other diagnoses

Back 43

Syndrome dc

Front 44

Describes the client’s health problem or response for which nursing therapy is given

Back 44

Problem statement (diagnostic label)

Front 45

words that have been added to some NANDA labels to give additional meaning to the diagnostic statement:

Back 45

Qualifiers

Front 46

Identifies one or more probable causes of the health problem

gives direction to required therapy and enables the RN to individualize client’s care

Back 46

Etiology (related factors and risk factors)

Front 47

cluster of signs and symptoms that indicate the presence of a particular diagnostic label (problem)

Back 47

Defining characteristics

Front 48

especially recommended for beginning diagnosticians because the signs and symptoms validate why the diagnosis was chosen.

Back 48

3 part PES

Front 49

deliberative, systematic phase of the nursing process that involves decision making and problem solving.

Back 49

Planning

Front 50

Activities in planning

Back 50

Prioritizing problems/diagnoses

Formulating client goals/desired outcomes

Selecting nursing interventions

Writing individualized

Front 51

any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.”

Back 51

Nursing interventions

Front 52

strategy for action that exists in the nurse’s mind.

Back 52

Informal ncp

Front 53

written or computerized guide that organizes information about client’s care.

Back 53

Formal ncp

Front 54

formal plan that specifies the nursing care for groups of clients with common needs.

Back 54

STANDARDIZED cp

Front 55

tailored to meet the unique needs of a specific client – needs that are not addressed by the standardized plan.

Back 55

Individualized cp

Front 56

preprinted to indicate the actions commonly required for a particular group of clients.

Back 56

Protocol

Front 57

developed to govern the handling of frequently occurring situations.

Back 57

Policies and procedures

Front 58

written document about policies, rules, regulations, or orders regarding client care.

Back 58

Standing Order

Front 59

learning activity as well as a plan of care, they may be more lengthy and detailed than care plans used by working nurses.

Back 59

Students cp

Front 60

the scientific principle given as the reason for selecting a particular nursing intervention

Back 60

Rationale

Front 61

visual tool in which ideas or data are enclosed in circles or boxes of shape and relationships between these are indicated by connecting lines or arrows.

Back 61

Concept map

Front 62

Activities of planning process

Back 62

Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plans

Front 63

indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior.

Back 63

CRITERION OF DESIRED PERFORMANCE

Front 64

Those activities NURSES are licensed to initiate (i.e., physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals

Back 64

Independent intervention

Front 65

Activities carried out under physician’s orders or supervision, or according to specified routines Ex: medication administration, IV therapy, diagnostic tests, treatments, diet, and activity.

Back 65

Dependent interventions

Front 66

Actions nurse carries out in collaboration with other health team members, such as PT, social workers, dieticians, and physicians Reflect overlapping responsibilities of health care team

Back 66

Collaborative interventions

Front 67

prescribe the care needed to avoid complications or reduce risk factors.

Back 67

Prevention intervention

Front 68

include teaching, referrals, physical care and other care needed

Back 68

Treatment

Front 69

the action phase in which the nurse performs the nursing interventions.

Back 69

Implementation

Front 70

consists of DOING and DOCUMENTING the activities ---the specific Nsg. Actions to carry out the interventions

Back 70

Implementing

Front 71

Intellectual skills that include: Problem solving Decision making Critical thinking Creativity

Back 71

Cognitive skill

Front 72

all of the activities, verbal and nonverbal, people use when interacting directly with one another. Effectiveness depends largely on nurse’s ability to communicate Include conveying knowledge, attitudes, feelings, interest

Back 72

Interpersonal skill

Front 73

Purposeful “hands-on” skills, such as manipulating equipment, giving injections, bandaging, moving,, lifting, and repositioning clients. Often called tasks, procedures, or psychomotor skills

Back 73

Technical skill

Front 74

Activities of implementing

Back 74

Reassessing the client

Determining the nurse’s need for assistance

Implementing nursing interventions

Supervising delegated care

Documenting nursing activities

Front 75

planned, ongoing, purposeful activity in which clients and health care professionals determine Client’s progress toward achievement of goals/outcomes, and The effectiveness of the nursing care plan.

Back 75

Evaluation

Front 76

ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients.

Back 76

Quality assurance

Front 77

Describes environmental and organizational characteristics that influence care, such as equipment and staffing.

Back 77

Structure evaluation

Front 78

Focuses on the manner in which the nurse uses the nursing process.

Back 78

Process evaluation

Front 79

focuses on demonstrable changes in the client’s health status as a result of nursing care.

Back 79

Outcome evaluation

Front 80

unexpected occurrence involving death or serious physical or psychological injury.

Back 80

Sentinel event

Front 81

process for identifying the factors that bring about deviations in practices that lead to the event.

Back 81

Root cause analysis

Front 82

oral, written, or computer-based communication intended to convey information to others

Back 82

Report

Front 83

Also called chart, or client record, is a formal, legal document that provides evidence of a client’s care.

Back 83

Clinical records

Front 84

serves as the vehicle by which different health professionals who interact with a client communicate with each other. (COMMUNICATION MEDIUM/CHANNEL)

Back 84

Clinical records

Front 85

Traditional client record Each person or department makes notations in a separate section of the client’s chart.

Back 85

Source oriented record

Front 86

Consists of written notes that include routine care, normal findings, and client problems. Uses chronological order.

Back 86

Narrative charting

Front 87

Established by Lawrence Weed Data are arranged according to client problem Health team contributes to the problem list, plan of care, and progress notes for each problem

Back 87

Pomr

Front 88

documentation system in which only abnormal or significant findings or EXCEPTIONS to norms are recorded.

Back 88

Cbe

Front 89

widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals.

Back 89

Kardex

Front 90

record typically indicates body temperature, pulse, RR, BP, weight, and, in some agencies other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activit

Back 90

Graphic record

Front 91

Enables RNs to record data QUICKLY & CONCISELY and provides an EASY-TO-READ record of the pt’s condition over time

Back 91

Flow sheets

Front 92

Purpose is to communicate specific information to a person or group of people.

Back 92

Reporting

Front 93

given to all nurses on next shift. Its purpose is to provide continuity of care for clients by providing the new caregivers a quick summary of client needs and details of care to be given.

Back 93

Chsnge of shift reports

Front 94

Are procedures in which two or more nurses visit selected clients at each client’s bedside to: Obtain information Provide client the opportunity to discuss their care. Evaluate the nursing care the client has received.

Back 94

Nursing rounds