Med-Surg Nursing - 01

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advanced practice nursing

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a specialized nursing practice that includes roles that emphasize health assessment, diagnosis, and treatment of conditions previously considered only within the physician's domain

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assessment

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collecting subjective and objective information about a patient

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case management

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a method used to coordinate and link health care services to patients and their families

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clinical (critical) pathway

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a description of practices that directs the entire health care team in the daily care goals for select health care problems; may include a nursing care plan, interventions specific for each day of hospitalization, and a documentation tool

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collaborative problems

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potential or actual complications of disease or treatment that nurses treat with other health care providers, most frequently physicians

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computerized documentation

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the use of computers to document patient care

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defining characteristics

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signs and symptoms, or the clinical cues that, in a cluster, lead to the nursing diagnosis

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evaluation

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the last phase of the nursing process in which the nurse determines if identified outcomes have been met and the overall accuracy of the assessment, diagnosis, and implementation phases are evaluated

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evidence-based practice

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the use of evidence (results from research) to improve quality and outcomes of health care

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expected patient outcomes

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goals that identify what is desired or expected of the patient as a result of care

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managed care

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a health care delivery concept that includes joint contributions of various disciplines and the use of case management

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nursing diagnosis

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the act of identifying and labeling human responses to actual or potential health problems; also is the label or concise statement that describes a clinical judgment about an individual, family, or community response to actual or potential health problems/life processes

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nursing implementation

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the use of nursing interventions to activate a plan

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nursing intervention

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

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nursing process

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an assertive, problem-solving approach to the identification and treatment of patient problems

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nursing

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the diagnosis and treatment of human responses to actual and potential health problems

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planning

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consists of setting goals and expected outcomes with the patient and family, when feasible, and determining strategies for accomplishing the goals

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standardized nursing languages

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readily understood common languages used among nurses to clearly define and evaluate nursing care and to improve communication