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  1. Nursing Outcomes Classification (NOC) & Nursing Interventions Classifications (NIC)
    The NOC is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. The outcomes have been linked to NANDA diagnoses and the NIC. NANDA, NIC, and NOC represent all domains of nursing and can be used together or separately. Each NOC outcome has a label name, a definition, a list of indicators to evaluate client status in relation to the outcome, and a five-point Likert scale to measure the client status. The 330 NOC outcomes include 311 individual, 10 family, and 9 community level outcomes.
  2. concept mapping
    a diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships between medical diagnoses, nursing diagnoses, assessment data, and treatments.
  3. evaluation
    The process of determining both the client's progress toward the attainment of expected outcomes and the effectiveness of nursing care
  4. outcomes
    measurable, expected, patient-focused goals that translate into observable behaviors
  5. nursing diagnosis
    clincial judgments about individual, family or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
  6. assessment
    a systematic, dynamic process by which the nurse, through interaction with the client, significant others, and health-care providers, collects and analyzes data about the client. Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic and lifestyle.
  7. problem oriented recording (POR)
    a system of documentation that follows a subjective, objective, assessment, plan, implementation and evaluation (SOAPIE) format. It is based on a list of identified patient problems to which each entry is identified.
  8. PIE charting
    more specifically, called "APIE," this method of documentation has an assessment, problem, intervention and evaluation (APIE) format and is a problem-oriented system used to document nursing process.
  9. nursing process
    a dynamic, systematic process by which nurses assess, diagnose, identify outcomes, plan, implement, and evaluate nursing care. It has been called "nursing's scientific methodology." Nursing process gives order and consistency to nursing intervention.
  10. managed care
    a concept purposefully designed to control the balance between cost and quality of care. Examples of managed care are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). The amount and type of health care that the individual receives is determined by the organization providing the managed care.
  11. interdisciplinary care
    a concept of providing care for a client in which members of various disciplines work together with common goals and shared responsibilites for meeting those goals
  12. Focus Charting
    a type of documentation that follows a data, action, and response (DAR) format. The main perspective is a client "focus," which can be a nursing diagnosis, a client's concern, change in status, or significant event in the client's therapy. The focus cannot be a medical diagnosis.
  13. critical pathways of care (CPCs)
    an abbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of time
  14. case manager
    the individual responsible for negotiating with multiple health care providers to obtain a variety of services for a client
  15. case management
    a health care delivered process, the goals of which are to provide quality health care, decrease fragmentation, enhance the client's quality of life, and contain costs. A case manager coordinates the client's care from admission to discharge and sometimes following discharge. Critical pathways of care are the tools used for the provision of care in a case management system.
  16. therapeutic relationship
    an interaction between two people (usually a caregiver and care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention.
  17. therapeutic communication
    caregiver verbal and nonverbal techniques that focus on the care receiver's need and advance the promotion of healing and change. TC encourages exploration of feelings and fosters understanding of behavioral motivation. it is nonjudgmental, discourages defensiveness and promotes trust.
  18. communication
    an interactive process of transmitting information between two or more entities
  19. countertransference
    refers to the nurse's behavioral and emotional response to the client. These responses may be related to unresolved feelings toward significant others from the nurse's past, or they may be generated in response to transference feelings on the part of the client.
  20. confidentiality
    the right of an individual to the assurance that his or her case will not be discussed outside the boundaries of the health-care team
  21. paralanguage
    nonverbal communication that includes physical appearance and dress, body movement and posture, touch, facial expressions, eye behavior and vocal cues
  22. public distance
    one that exceeds 12 feet. Examples include speaking in public or yelling to someone some distance away. This distance is considered public space and communicants are free to move about in it during the interaction.
  23. social distance
    about 4-12 feet away from the body. Interactions at this distance include conversations with strangers or acquaintances, such as at a cocktail party or in a public building
  24. personal distance
    approximately 18-40 inches and is reserved for interactions that are personal in nature, such as close conversations with friends or colleagues
  25. intimate distance
    the closest distance that individuals will allow between themselves and others (intimate nature). US=0-18 inches.
  26. density
    refers to the number of people within a given environmental space. it has been shown to influence interpersonal interaction.
  27. territoriality
    the innate tendency to own space. Individuals lay claim to areas around them as their own. This influences communication when an interaction takes place in the territory "owned" by one or the other. Interpersonal communication can be more successful if the interaction takes place in a "neutral" area.
  28. professional boundaries
    these boundaries limit and outline expectations for appropriate professional relationships with clients. They separate therapeutic behavior from any other behavior that, well intentioned or not, could lessen the benefit of care to clients.
  29. personal boundaries
    these are boundaries that individuals define for themselves. These include physical distance boundaries, or just how close individuals will allow others to invade their physical space, and emotional boundaries, or how much individuals choose to disclose of their most private and intimate selves to others
  30. social boundaries
    these are established within a culture and define how individuals are expected to behave in social situations
  31. material boundaries
    these are physical properties that can be seen, such as fences that border land
  32. transference
    occurs when the client unconsciously attributes (or "transfers") to the nurse feelings and behavioral predispositions formed toward a person from his or her past. These feelings toward the nurse may be triggered by something about the nurses's appearance or personality that remind the client of the person.
  33. sympthay
    the nurse actually "shares" what the client is feeling, and experiences a need to alleviate distress.
  34. empathy
    a process wherin an individual is able to see beyond outward behavior and sense accurately another's inner experience at a given point in time. With empathy, the nurse can accurately perceive and understand the meaning and relationship of the client's thoughts and feelings.
  35. genuineness
    refers to the nurse's ability to be open, honest, and "real" in interactions with the client. To be "real" is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be apparent in the therapeutic relationship.
  36. unconditional positive regard
    to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior
  37. concrete thinking
    focuses thought processes on specifics rather than generalities and immediate issues rather than eventual outcomes
  38. rapport
    implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.
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