Taylor Chapter 11-16

Front 1

assess

Back 1

to systematically and continuously collect, validate, and communicate patient data

Front 2

concept mapping

Back 2

instructional strategy that requires learners to identify, display and link key concepts

Front 3

critical thinking

Back 3

thought that is disciplined, comprehensive, based on intellectual standards, and as a result, well reasoned

Front 4

critical thinking indicators

Back 4

evidence-based descriptions and behaviors that demonstrate the knowledge, characteristics and skills that promote critical thinking in critical practice

Front 5

decision making

Back 5

purposeful, goal-directed effort applied in a systematic way to make a choice among alternatives

Front 6

evaluate

Back 6

measurement of the extent to which the patient has achieved the goals specified in the care plan; care plan is terminated or revised if needed

Front 7

expected outcomes

Back 7

specific measurable criteria used to evaluate whether a patient goal has been met

Front 8

implement

Back 8

carry out the plan of care

Front 9

intuitive problem solving

Back 9

direct understanding of a situation based on a background of experience, knowledge, and skill that makes decisions making possible

Front 10

nursing diagnosis

Back 10

actual or potential health problem that an independent nursing intervention can prevent and resolve

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Nursing Process

Back 11

five step systematic method for giving patient care; assess, diagnose, plan, implement, evaluate

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Plan

Back 12

establish patient goals, to prevent, reduce, or resolve the problems identified in the nursing diagnosis and determination of related nursing interventions

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Scientific Problem Solving

Back 13

scientific method of problem solving; identification, data collection, hypothesis, plan actions, hypothesis testing, interpret results, evaluate

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standards for critical thinking

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clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate, fair

Front 15

trial and error problem solving

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testing solutions until finding one that works

Front 16

assessing

Back 16

- identify nursing and medical concerns
- determine credibility of info
- identify & determine risks for abnormal findings
- distinguish relevant from irrelevant data
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Front 17

cue

Back 17

significant information that is helpful in making decisions

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emergency assessment

Back 18

rapid focused assessment to determine potentially fatal situations

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focused assessment

Back 19

conducted to assess a specific problem; pertinent history and body regions

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inference

Back 20

the judgement reached about a cue

Front 21

initial assessment

Back 21

comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgement about patients health status, ability to manage their care, need for nursing, and to develop a care plan

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interview

Back 22

planned communication for a specific purpose

Front 23

minimum data set

Back 23

a standard established by health care institutions that specifies the information that must be collected from every patient

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nursing history

Back 24

assessment of the patient by interview to identify the patients health status, strengths, health problems, risks, and need for care

Front 25

objective data

Back 25

information perceptible by tha senses, can be observed

Front 26

observation

Back 26

deliberate use of the five senses to gather data

Front 27

physical assessment

Back 27

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care

Front 28

review of systems ROS

Back 28

physical examination of all body systems in a systematic matter as part of the nursing assessment

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subjective data

Back 29

information perceived only by the affected person

Front 30

time-lapsed assessment

Back 30

an assessment to compare a patients data to baseline data that was gathered earlier

Front 31

validation

Back 31

act of confirming or verifying

Front 32

actual nursing diagnosis

Back 32

problems validated by the presence of major defining characteristics
four components: label, definition, defining characteristics, and related factors

Front 33

collaborative problems

Back 33

actual or potential health problem that may occur from complication of disease, diagnostic studies, or treatment regimen

Front 34

data cluster

Back 34

grouping of patient data or cues that points to the existence of a patient health problem

Front 35

diagnosing

Back 35

-creating a list of suspected problems/diagnosis
- ruling out similar problems
- naming actual/potential problems and clarifying causes/contributions
- determining managment of risk factors
- identify resources and areas for health promotion

Front 36

diagnostic error

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failure to detect an actual unhealthy behavior

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health problem

Back 37

condition related to health requiring intervention if disease or illness is to be prevented

Front 38

medical diagnosis

Back 38

statement about a specific disease process using terminology accepted by the medical profession

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possible nursing diagnosis

Back 39

statements describing a suspected problem for which additional data is needed to confirm or rule out

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risk nursing diagnosis

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clinical judgements that an individual, family, or community is more vulnerable to develop than others in the same or similar situation

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standard

Back 41

acceptable, expected level of performance established by authority, custom, or consent

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syndrome nursing diagnosis

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cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain event or situation

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wellness diagnosis

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clinical judgement about and individual, family, or community in transition from a specific level of wellness to a higher one

Front 44

clinical pathways

Back 44

case management tools used to communicate the standardized plan of care for a particular group of patients

Front 45

computerized plans of nursing care

Back 45

care plans developed by software programs that list causes, goals, interventions, nursing/medical diagnosis

Front 46

consultation

Back 46

process in which two or more individuals with varying degrees of experience deliberate about a problem and it's solution

Front 47

criteria

Back 47

specified behavior; specifies how a patient must preform a desired behavior

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discharge planning

Back 48

systematic process of preparing the patient to leave the health care facility and maintaining continuing care

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expected outcome

Back 49

specific, measurable criteria to evaluate whether or not apatient goal has been met

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goal

Back 50

an aim or end

Front 51

initial planning

Back 51

addresses each problem listed in the nursing diagnosis and identifies patient goals and related nursing care

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Kardex care plan

Back 52

documentation plan that encompasses:
1. prescriptions for nursing care related to activites of daily living
2. nursing diagnosis, patient goals, nursing orders
3. nursing care related to diagnostic measures and the medical regimen

Front 53

nursing intervention

Back 53

treatment based on clinical judgement and knowledge, that a nurse preforms to enhance patient outcomes

Front 54

nursing intervention classification
NIC

Back 54

comprehensive list of nursing interventions that can be used by nurses in all settings to facilitate identifying appropriate interventions

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ongoing planning

Back 55

planning carried out by the nurse who interacts with the patient to keep plan up to date, to resolve health problems, mange risk factors, and promote function

Front 56

outcome identification

Back 56

observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnosis and general problems list, along with a time frame for accomplishing these outcomes

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patient outcome

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expected conlclusion to a patients health problems

Front 58

plan of nursing care

Back 58

written guide that directs the efforts of the nursing team
diagnosis, outcomes, and related interventions

Front 59

planning

Back 59

-establish priorities
- identify expected outcomes
- select nursing intervention
- communicate care plan

Front 60

standardized care plans

Back 60

prepared plan of care that identifies nursing diagnosis, patient goals, and related nursing orders, common to a specific problem or population

Front 61

collaborative interventions

Back 61

interdependent nursing actions performed jointly by nurses and other health care personel

Front 62

delegation

Back 62

transferring of the responsibility of the performance of an activity, while retaining accountability for the outcome

Front 63

evidence-based practice

Back 63

nursing care provided that is supported by sound scientific rationale

Front 64

implementing

Back 64

- carry out the care plan
- continue date collection
- modify plan as needed
- document care

Front 65

nursing interventions

Back 65

any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes

Front 66

protocols

Back 66

written plan that details nursing activities to be executed in certain situations

Front 67

standing orders

Back 67

document that details the care to be implemented in certain situations, when a doctor is not present; may expand scope of nursing responsibility

Front 68

concurrent evaluation

Back 68

evaluation of nursing care and patient outcomes while patient is receiving care, patient interviews and chart review to determine whether criteria are met

Front 69

evaluating

Back 69

- measure how well the patient has achieved desired outcomes
- identify factors contributing to patient's success or failure
- modify care plan if needed

Front 70

nursing audit

Back 70

method of evaluating the outcomes of nursing care or the process by the which these outcomes are achieved using review of patient records

Front 71

outcome evaluation

Back 71

evaluation that focuses on measurable changes in the health status of a patient or the end results of nursing care

Front 72

peer review

Back 72

evaluation at the closest point to the patient and an ongoing tool for professional growth

Front 73

Nursing Process

Back 73

- assess patient to determine need for nursing care
- determine nursing diagnosis for actual and potential health problems
- identify expected outcomes and plan care
- implement care
- evaluate results

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Characteristics of Nursing Process

Back 74

- pateint cenered

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Nursing Process Characteristics

Back 75

patient centered, systematic, dynamic, interpersonal, outcome oriented, universally applicable in nursing situations

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Benefits of Nursing Process

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continuity of care, promotes patient participation, improved quality of care,efficient use of time and resources, expectations and standards of care are met, holds nurses accountable, care is holistic/continuous/systematic

Front 77

Sources of patient data

Back 77

patient, family, nursing/medical records, consultations, health care team, diagnostic results, relevant literature

Front 78

Methods of Data collection

Back 78

observation, interview, physical assessment

Front 79

Communication Techniques

Back 79

paraphrasing, clarifying, focusing, summarizing, open-ended questions

Front 80

Nursing Diagnosis 1

Back 80

clinical judgement about individual, family or community responses to actual or potential health/life processes

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Nursing Diagnosis 2

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identifications of factors that contribute to or cause health problems

Front 82

Nursing Diagnosis 3

Back 82

provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Front 83

Nursing Diagnosis 4

Back 83

- determined by the nurse
- clinical judgement about patient
- human responses to disease or treatment
- may change

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Medical Diagnosis

Back 84

- determined by physician
- indicates disease, illness
- doesn't change

Front 85

Types of nursing diagnosis

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- actual, risk, possible, syndrome, wellness, collaborative

Front 86

Formulating Nursing Dx - actual

Back 86

1. Label/Problem
related to
2. Contributing Factors/Etiology
as evidenced by/secondary to
3. Signs/Symptoms

Front 87

Formulating Nursing Dx - actual

Back 87

1. What's the problem
2. what causes the problem
3. what evidence do you have that you've correctly identified the problem

Front 88

Rules for Nursing Dx

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- don't use medical diagnosis as part of
- follow correct format

Front 89

Example of nursing dx- actual

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1. acute pain
2. tissue trauma
3. sharp right knee pain as expressed by patient

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Example of nursing dx- risk

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1. risk for injury
2. impaired mobility secondary to arthritis

Front 91

Formulating Nursing Dx - risk

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1. potential problem
2. risk factors
3. no evidence
4. problem does not exist but could if no interventions are done

Front 92

Planning/Outcomes

Back 92

- patient-centered
- outcomes or measurable goals
- within time constraints
- individualized
- attainable/realistic/specific
- short term and long term expectations

Front 93

Planning/Outcomes 2

Back 93

- outcomes always focus on specific patient behaviors or conditions
- prioritized according to Maslow's heirarchy

Front 94

Interventions 1

Back 94

- what nurse will do to reach the planning outcomes or goals
- can be direct or indirect care but always focus on patient outcomes

Front 95

Interventions 2

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- care plan/issue/patient specific
- consistent with professional standards of care, protocols, policies, procedures of hospital, and EBP
- include relevant patient/family teaching

Front 96

Evaluation 1

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- nurse and patient together measure how well outcomes have been achieved
- goal may be met, partially met, or not met

Front 97

Evaluation 2

Back 97

- terminate the plan of care when each expected outcome is achieved
- modify plan of care if needed
- continue care plan if more time is needed
- data supporting evaluation should be included

Front 98

Decision-Making process model

Back 98

DIGEST
- describe situation
- identify the problem
- get the facts
- evaluate the alternatives
- select alternative
- take action

Front 99

Method of Critical Thinking

Back 99

- purpose of thinking
- adequacy of knowledge
- potential problems
- helpful resources
- critique of judgment/decision
- focused critical thinking guides

Front 100

How to think critically

Back 100

- think independently
- fair minded
- intellectually humble
- good faith and integrity
- curious and persevering
- disciplined, creative, confident