Nursing Basics-Chapter 7: The Nursing Process

Front 1

Assessing

Back 1

The process of collecting, organizing, validating, and recording data (information) about a client's health status

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Data

Back 2

Information

Front 3

Symptoms

Back 3

Subjective Data. Information (data) apparent only to the person affected that can be described or verified only by that person.

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Interview

Back 4

A planned communication; a conversation with purpose

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Rapport

Back 5

A relationship between two or more people of mutual trust and understanding

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Cephalocaudal

Back 6

Proceeding in the direction from head to toe.

Front 7

Validation

Back 7

The determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate and that the conclusion or diagnosis is justified by the data.

Front 8

Cues

Back 8

Any piece of information or data that influences decisions

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Inferences

Back 9

Interpretations or conclusions made based on cues or observed data

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Taxonomy

Back 10

A classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles.

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Diagnosis

Back 11

A statement or conclusion concerning the nature of some phenomenon.

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Etiology

Back 12

The causal relationship between a problem and its related or risk factors

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Nursing Diagnosis

Back 13

The nurse's clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

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Risk Factors

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Factors that cause a client to be vulnerable to developing a health problem.

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Qualifiers

Back 15

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

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Defining Characteristics

Back 16

Client signs and symptoms that must be present to validate a nursing diagnosis

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Planning

Back 17

An ongoing process that involves: a) assessing a situation, b) establishing goals & objectives based on assessment of a situation or future trends, and c) developing a plan of action that identifies priorities, delineates who is responsible, determines deadlines, and describes how the intended outcome is to be achieved and evaluated.

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Nursing Intervention

Back 18

Any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes

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Discharge Planning

Back 19

The process of anticipating and planning for client needs after discharge.

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Individualized Care Plan

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

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Protocols

Back 21

A predetermined and preprinted plan specifying the procedure to be followed in a particular situation

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Policies

Back 22

Rules developed to govern the handling of frequently occurring situations.

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Procedures

Back 23

Steps used in carrying out policies or activities

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Standing Order

Back 24

A written document about policies, rules, regulations, or orders regarding client care; gives nurses the authority to carry out specific actions under certain circumstances

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Rationale

Back 25

The scientific reason for selecting a specific action

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Concept Map

Back 26

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

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Multidisciplinary Care Plan

Back 27

A standardized plan that outlines the care required for clients with common, predictable-usually medical-conditions

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Collaborative Care Plan, see Critical Pathways

Back 28

Multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes

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Priority Setting

Back 29

A process of establishing a preferential order for nursing strategies

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Goals/Desired Outcomes

Back 30

A part of a care plan that describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.

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Nursing Outcomes Classification (NOC)

Back 31

A taxonomy for describing client outcomes that respond to nursing interventions

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Indicator

Back 32

An observable patient state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language

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Independent Interventions

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Activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills

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Dependent Interventions

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Those activities carried out on the order of a physician, under a physician's supervision, or according to specified routines

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Collaborative Interventions

Back 35

Action the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians

Front 36

Nursing Interventions Classifications (NIC)

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A taxonomy of nursing actions each of which includes a label, a definition, and a list of activities

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Implementing

Back 37

The phase of the nursing process in which the nursing care plan is put into action

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Evaluating

Back 38

A planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes

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Evaluation Statement

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A statement that consists of two parts: a conclusion and supporting data

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Quality Assurance (QA)

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

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Sentinel Event

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An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

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Quality Improvement (QI)

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An organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI)

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The Nursing Process

Back 43

Assessment
Diagnosing
Planning
Implementing
Evaluating

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The Nursing Process-Assessing

Back 44

1) Collect Data
2) Organize Data
3) Validate Data
4) Document Data

Front 45

The Nursing Process-Diagnosing

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1) Analyze Data
2) Identify health problems, risks and strengths
3) Formulate diagnostic statements

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The Nursing Process-Planning

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1) Prioritize problems/diagnoses
2) Formulate Goals/desired outcomes
3) Select nursing interventions
4) Write nursing orders

Front 47

The Nursing Process-Implementing

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1) Reassess the client
2) Determine the client's need for assistance
3) Implement the nursing interventions
4) Supervise delegated care
5) Document nursing activities

Front 48

The Nursing Process-Evaluating

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1) Collect data related to outcomes
2) Compare data with outcomes
3) Related nursing actions to client goals/outcomes
4) Draw conclusions about problem status
5) Continue, modify, or terminate the client's care plan

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Types of Assessments

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1) Initial Assessment
2) Problem-focused Assessment
3) Emergency Assessment
4) Time-lapsed Assessment

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Signs

Back 50

Objective data (overt data). Detectable by the observer or can be measured or tested against and accepted standard