Fundamentals Of Nursing Key Terms, Ch 13,14,15

Front 1

Assignment

Back 1

A downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another

Front 2

Collaborative Care Plan

Back 2

Critical Pathway: Multidisciplanary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes

Front 3

Collaborative Interventions

Back 3

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

Front 4

Dependent Interventions

Back 4

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

Front 5

Discharge Planning

Back 5

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

Front 6

Formal Nursing Care Plan

Back 6

a written or computerized guide that organizes information about the client's care.

Front 7

Goal/Desired Outcomes

Back 7

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.

Front 8

Independent Interventions

Back 8

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

Front 9

Indicator

Back 9

an observable patient state, behavior, or self-reported perception or evaluation similar to desired outcomes in traditioal language

Front 10

Individualized Care Plan

Back 10

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

Front 11

Informal Plan

Back 11

a strategy for action that exists in the nurse's mind

Front 12

Multidisciplainary Care Plan

Back 12

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

Front 13

Nursing Interventions

Back 13

any treatments, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes

Front 14

Nursing Interventions Classification (NIC)

Back 14

a taxonomy of nursing interventions developed by Iowa Intervention Project

Front 15

Nursing Orders

Back 15

instructions written on the care plan to direct the specific nursing activities that help the client achieve desired outcomes/goals.

Front 16

Nursing Outcomes Classification (NOC)

Back 16

a taxonomy for describing client outcomes that respond to nursing interventions

Front 17

Policies

Back 17

rules developed to govern the handling of frequently occurring situations.

Front 18

Priority Setting

Back 18

the process of establishing a preferential order for nursing strategies.

Front 19

Procedures

Back 19

steps used in carrying out policies or activities

Front 20

Protocols

Back 20

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

Front 21

Rationale

Back 21

the scientific reason for selecting a specific action.

Front 22

Standardized Care Plan

Back 22

preprinted guides for giving nursing care to clients with common needs (e.g. nursing diagnosis)

Front 23

Standing Order

Back 23

a written document about policies, rules, regulation, or orders regarding client care; give nurses the authority to carry out specific actions under certain curcumstances.

Front 24

Activities

Back 24

the specific nursing actions needed to carry out the interventions (or nursing orders)

Front 25

Cognitive Skills

Back 25

(intellectual skills) that include problem solving, decision making, critical thinking, and creativity.

Front 26

Evaluating

Back 26

a planned ongoing, purposeful activity in which clients and health care professionals monitor progress.

Front 27

Evaluation Statement

Back 27

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

Front 28

Implementing

Back 28

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

Front 29

Interpersonal Skills

Back 29

all the verbal and nonverbal activities people use when communicating directly with one another

Front 30

Outcome Evaluation

Back 30

focuses on demonstratable changes in the client's health status as result of nursing care

Front 31

Process Evaluation

Back 31

a component of quality assurance that focuses on how care was given

Front 32

Quality Improvement

Back 32

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)

Front 33

Quality-Assurance Program

Back 33

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

Front 34

Structure Evaluation

Back 34

focuses on the setting which care is given

Front 35

Technical Skills

Back 35

hands-on skills such as those required to manipulate equipment, administer injections, or move or reposition patients

Front 36

Change -of-Shift Report

Back 36

a report given to nurses on the next shift

Front 37

Chart

Back 37

a formal, legal document that provides evidence of a client's care (Client Record)

Front 38

Charting

Back 38

the process of making an entry on a client record (Charting or Recording)

Front 39

Charting by Exception (CBE)

Back 39

a documentation system in which only significant findings or exceptions to the norm are recorded

Front 40

Discussion

Back 40

an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem

Front 41

Flowsheet

Back 41

a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form

Front 42

Focus Charting

Back 42

a method of charting that uses key words or foci to describe what is happening to the client

Front 43

Kardex

Back 43

the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date

Front 44

Narrative Charting

Back 44

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

Front 45

PIE

Back 45

an acronym for a charting model that follows a recording sequence of Problems, Interventions, and Evaluation of the effectiveness of the interventions.

Front 46

Problem-Oriented Medical Record (POMR)

Back 46

data about the client are recored and arranged according to the client's problems, rather than according to the source of the information (also Problem-Oriented Record (POR))

Front 47

Progress Notes

Back 47

chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes

Front 48

Record

Back 48

a written communication providing formal, legal documentation of a client's progress.

Front 49

Recording

Back 49

the process ofmaking written entries about a client on the medical record

Front 50

Report

Back 50

whether oral or written, it should be concise, including pertinent information but no extraneous detail

Front 51

SOAP

Back 51

an acronym for a charting method that follows a recording sequence of Subjective data, Objective data, Assessment and Planning.

Front 52

Source-Orientend Record

Back 52

a record in which each person or department makes notations in a separate section or sections of the client's chart

Front 53

Standards of Care

Back 53

the skills and learning commonly possessed by members of a profession

Front 54

Delegation

Back 54

the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome.

Front 55

Confidentiality

Back 55

any information a subject relates will not be made public or available to others without the subject's consent

Front 56

Computer-Based Client Record

Back 56

electronic client data retrievable by caregivers and other personnel who reqiure data.

Front 57

Case Management Model

Back 57

a method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health continuum.