Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
33 Cards in this Set
- Front
- Back
|
evaluation statement
|
consists of conclusion and supporting data
|
|
|
outcome evaluation
|
focuses on demonstrable changes in the clients health status as a result of nursing care
|
|
|
process evaluation
|
focuses on how care was given
-is care relevant to clients needs? -is care appropriate, complete, timely? |
|
|
implementing
|
consists of doing and documenting the activites that are the specific nursing actions needed to carry out interventions
|
|
|
dependent interventions
|
activities carried out under physicians orders or supervisor or according to specifed routines
|
|
|
independent interventions
|
activities that nurse are licensed to initiate on the basis of their knowledge and skills
|
|
|
nursing outcomes classifications (NOC)
|
a taxonomy for describing client outcomes that respond to nursing interventions
|
|
|
goals/ desired outcomes
|
in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
|
|
|
priority settings
|
process of establishing a preferential sequence for addressing nursing diagnosis and interventions
|
|
|
collaborative care plans/ critical pathways
|
sequence that must be given on each day during the projected length of stay for the specific type of condition
|
|
|
concept map
|
visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationship between these are indicated by connecting lines or arrows
|
|
|
standing order
|
a written doc about policies, rules and regulations regarding client care
|
|
|
policeis and procedures
|
developed to govern the handling of frequently occuring situations
|
|
|
formal nursing care plan
|
a written or computerized guide that organizeds info about the clients care, provides continuity of care
|
|
|
nursing intervention
|
"any treatment, based upon clinical judgement and knowledge, taht a nurse performs to enhance patient/client outcome"
|
|
|
discharge planning
|
proces of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care and should be addressed in each clients care plan
|
|
|
defining characteristics
|
the cluster of signs and symptoms that indicate the presence of a particular diagnostic label
|
|
|
taxonomy
|
classification system or set of categories arranged based on a single principle or set of principles
|
|
|
qualifiers
|
words that have been added to some NANDA labesl to give additional meaning
--ex ----deficient, impaired, decreased, ineffective, compromised |
|
|
possible nursing diagnosis
|
evidence about a health problem is incomplete or unclear- needs more data either to support or to refute it
|
|
|
wellness diagnosis
|
"describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement"
|
|
|
risk nursing diagnosis/ _____ risk factors
|
a clinical judgement that a problem does not exist, but a presence of _____ indicates that a problem is likely to develop unless nurses intervene
|
|
|
diagnosis
diagnostic label |
statement or conclusion regarding the nature of phenomenon..... the NANDA name for it
|
|
|
nursing diagnosis
|
the clients problem statement, consisting of the NANDA name plus etiology (causal relationship between a problem and its related or risk factors)
|
|
|
cues
|
subjective or objective data that can be directly observed by the nurse- client/ nurse can see, hear, smell, feel or measure
|
|
|
inferences
|
nurses interpretation or conclusion made based on cues
|
|
|
opend ended questions
|
associated with nondirective interview, invite clients to discover and explore, elaborate, clarify ,or illustrate their thoughts or feelings
|
|
|
closed question
|
used in the directive interview, are restrictive and generally require only "yes" or "no" or short factual answers giving specific info
|
|
|
rapport
|
an understanding between two or more people
|
|
|
subjective data / symptoms/covert data
|
apparent only to the person affected and can be describe or verified only by that person
---itching, pain, worries |
|
|
objective data/signs/overt data
|
detectable by an observer or can be measured or tested against an acceptable standard
---discoloration, broken bones |
|
|
data
|
info
|
|
|
assessing
|
systematic and continuous collection, organization validation and documentation of data
|
