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12 Cards in this Set

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Compliance

Implementation or fulfillment of a treatment or therapeutic plan buy a patient

Medication error

Any preventable adverse drug event involving inappropriate medication use

Non-compliance

An informed decision on the part of the patient not to adhere to a therapeutic plan or suggestions

Nursing process

An organizational framework for the practice of Nursing all steps taken by the nurse in caring for a patient assessment nursing diagnosis planning implementation and evaluation

Prescriber

Any health care professional license by the appropriate regulatory board to prescribe medication

5 steps of the nursing process

1. Assessment


2. Nursing Diagnosis


3. Outcome Planning


4. Implementation/ Education


5. Evaluation

7 Elements (needs) of the Nursing Process

1. physical. 5. Financial


2. Emotional. 6. cultural


3. Spiritual. 7. Cognitive


4. Sexual

6 major initiatives that are needed in the nursing process

1. patient centered care


2. teamwork and collaboration


3. Evidence based practice


4. Quality improvement


5. Safety


6. informatics

Info available through the senses


Objective data

What is seen, felt, heard, or smelled

Examples of objective data (4)

1. Labs.


2. Diagnostic procedures


3. Physical assessment


4. Exam Findings

Examples of specific objective data

Chart. Labs. Diagnostic procedures


Physical assessment. Exam findings

defined as a clinical judgement about individual, family or community responses to actual or potential health problems or life processes which provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Nursing Diagnosis