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45 Cards in this Set
- Front
- Back
nursing process
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a professional nurse's approach to identfiyig, dianosing, and treating human responses to health and illness
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assessment
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the deliberate and systematic collection of data about a patient
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database
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a composition of knowledge that helps you identify what to assess on your patient
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health history
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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
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cue
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information you obtain through use of the senses
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inference
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your judgement or inerpretation of cues
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subjective data
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the patient's verbal descriptions of their health problems, Provided only by the patient.
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objective data
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observations or measurements of a patient's health status
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open-ended questions
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prompts patients to describe a situation in more than one or two words.
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back-channeling
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the practice of giving positive comments such as, "all right,"go on," or "uh-huh" to the speaker
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validation
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the comparison of data with another source to confirm their accuracy
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nursing diagnosis
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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
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medical diagnosis
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the identification of a disease condition based on an evaluationof physical signs, symptoms, history, and diagnostic tests and procedures
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nursing diagnostic process
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flows from the assessment process and includes data clustering, interprtation and analysis, identifying patient needs, and formulatig the nursing diagnosis or collaborative problem
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data clusters
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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
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data analysis
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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
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NANDA international (NANDA-1)
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develpoed a model for organizing nursing diagnoses for documentation, auditing, and communication processes
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defining characteristics
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the clinical criteria or assessment findings that support an actual nursing diagnosis
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related factor
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a condition or etiologic factor that appears to show some type of paterned relationship with the nursing diagnosis
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etiology
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is always within the domain of nursing practice and a condition that responds to nursing interventions
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planning
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involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions
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goal
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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
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expected outcomes
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observable effects (e.g. change in patient's physical condition or behavior) that are the result of an intervention
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nursing-sensitive outcome
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a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions
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scientific rationale
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reason based on supporting literature, why a specific nursing action was chosen
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independent nursing interventions
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nurse-initiated interventions that nurses initiate on their own to act on a patients behalf
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dependednt nursing interventions
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physician-initiated interventions or actions that require and order from a physician or another health care professional
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collaborative interventions
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therapies that require knowledge, skill, and expertise of multiple health care professionals
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interdisciplinary care plan
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includes contributions from all disciplines involved in patient care. It improves the coordination of all patient therapies
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concept map
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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
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critical pathways
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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
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consultation
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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
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Implementation
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the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care
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nursing intervention
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any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes
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direct care interventions
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tretments persormed through interactions with patients
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indirect care interventions
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treatments performed away from the patient but on the behalf of the patient or group of patients
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clinical guideline
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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
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standing order
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a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems
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instrumental activities of daily living (IADLs)
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includes skills such as shopping, preparing meals, writing checks, and taking medications
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counseling
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a direct care method that helps patients use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships
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evaluation
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determines if expected outcomes are met, not if nursing interventions were completed
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collaborative problem
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physiological complications that that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes
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closed-ended questions
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a form of questions that limits a respondent's answer to one or two words
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standard of care
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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
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functional health patterns
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method for organizing assessment data based on the level of patient function in specific areas, for examole, mobility
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