Test 3 Nursing Process Ii Terminology

Front 1

nursing process

Back 1

a professional nurse's approach to identfiyig, dianosing, and treating human responses to health and illness

Front 2

assessment

Back 2

the deliberate and systematic collection of data about a patient

Front 3

database

Back 3

a composition of knowledge that helps you identify what to assess on your patient

Front 4

health history

Back 4

includes information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system

Front 5

cue

Back 5

information you obtain through use of the senses

Front 6

inference

Back 6

your judgement or inerpretation of cues

Front 7

subjective data

Back 7

the patient's verbal descriptions of their health problems, Provided only by the patient.

Front 8

objective data

Back 8

observations or measurements of a patient's health status

Front 9

open-ended questions

Back 9

prompts patients to describe a situation in more than one or two words.

Front 10

back-channeling

Back 10

the practice of giving positive comments such as, "all right,"go on," or "uh-huh" to the speaker

Front 11

validation

Back 11

the comparison of data with another source to confirm their accuracy

Front 12

nursing diagnosis

Back 12

a clinical judgement about individual, family, or community responses to actual or potential halth problems or life prcesses. Provides the basis selection of nursing interventions to achieve outcomes for which the nurse is accountable

Front 13

medical diagnosis

Back 13

the identification of a disease condition based on an evaluationof physical signs, symptoms, history, and diagnostic tests and procedures

Front 14

nursing diagnostic process

Back 14

flows from the assessment process and includes data clustering, interprtation and analysis, identifying patient needs, and formulatig the nursing diagnosis or collaborative problem

Front 15

data clusters

Back 15

organization of all of your data so that it is meaningful and usable. During this a cue or an individual sign, symptom, or finding will alert your thinking more than others

Front 16

data analysis

Back 16

involves recognizing patterns or trendsin the clustered data, comparing them with standards, and then coming to a reasoned conclusion about a patients response to a health problem

Front 17

NANDA international (NANDA-1)

Back 17

develpoed a model for organizing nursing diagnoses for documentation, auditing, and communication processes

Front 18

defining characteristics

Back 18

the clinical criteria or assessment findings that support an actual nursing diagnosis

Front 19

related factor

Back 19

a condition or etiologic factor that appears to show some type of paterned relationship with the nursing diagnosis

Front 20

etiology

Back 20

is always within the domain of nursing practice and a condition that responds to nursing interventions

Front 21

planning

Back 21

involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions

Front 22

goal

Back 22

a specific and measurable behavior or response that reflects the patients highest possible level of wellness and independence in function. Is realistic and besed on patient needs and resources

Front 23

expected outcomes

Back 23

observable effects (e.g. change in patient's physical condition or behavior) that are the result of an intervention

Front 24

nursing-sensitive outcome

Back 24

a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions

Front 25

scientific rationale

Back 25

reason based on supporting literature, why a specific nursing action was chosen

Front 26

independent nursing interventions

Back 26

nurse-initiated interventions that nurses initiate on their own to act on a patients behalf

Front 27

dependednt nursing interventions

Back 27

physician-initiated interventions or actions that require and order from a physician or another health care professional

Front 28

collaborative interventions

Back 28

therapies that require knowledge, skill, and expertise of multiple health care professionals

Front 29

interdisciplinary care plan

Back 29

includes contributions from all disciplines involved in patient care. It improves the coordination of all patient therapies

Front 30

concept map

Back 30

provides a visual representation of the complex level of thinking that nursing care requires. Creates a visual representation of your patient's medical problems, nursing assessment data, nursing diagnoses, and their relationship to one another

Front 31

critical pathways

Back 31

patient care managemnet plans that provide the multidisciplinary health team with the activities and tasks to be put into practice sequentially; their main purpose is to deliver timely care at each phase of the care process for a specific type of patient

Front 32

consultation

Back 32

a process in which you seek the expertise of a specialist, such as your nursing instructor or a clinical nurse specialist, to identify ways to handle problems in patient care management or in he planning and impelementation of therapies. Based on the problem-solving approach, and the consultant is the stimulus for change

Front 33

Implementation

Back 33

the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care

Front 34

nursing intervention

Back 34

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

Front 35

direct care interventions

Back 35

tretments persormed through interactions with patients

Front 36

indirect care interventions

Back 36

treatments performed away from the patient but on the behalf of the patient or group of patients

Front 37

clinical guideline

Back 37

a document that guides decisions and interventions for specific health care problems or conditions, such as the treatment for a patint who has had a stroke or the administration of chemotherapy

Front 38

standing order

Back 38

a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems

Front 39

instrumental activities of daily living (IADLs)

Back 39

includes skills such as shopping, preparing meals, writing checks, and taking medications

Front 40

counseling

Back 40

a direct care method that helps patients use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships

Front 41

evaluation

Back 41

determines if expected outcomes are met, not if nursing interventions were completed

Front 42

collaborative problem

Back 42

physiological complications that that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes

Front 43

closed-ended questions

Back 43

a form of questions that limits a respondent's answer to one or two words

Front 44

standard of care

Back 44

minimum level of care accepted to ensure high-quality care to patients. Define the types of therapies typically administered to patients with defined problems or needs

Front 45

functional health patterns

Back 45

method for organizing assessment data based on the level of patient function in specific areas, for examole, mobility