Problem solving approach that nurses use to define pt problems and select appropriate treatment
care planning tool that assists in critical thinking and forming associations between a pt's ND and interventions
active, purposeful, organized, cognitive processes used to carefully examine ones thinking and the thinking of others
Process involving critical appraisal of info that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking
Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking
evidence based knowledge
Knowledge that is derived from the integration of best research, clinical expertise, and patient values
Judgment or interpretation of informational cues. Taking one proposition as a given and guessing that another proposition follows.
systematic problem solving method by which nurses individualize care for each pt. assessment, diagnosis, planning, implementation, evaluation.
methodical systematic approach to explore conditions and develop solutions including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem
Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking
Codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas.
activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.
close ended question
form of a question that limits pts answer to one or two words.
information that a nurse acquires through hearing, visual observations, touch, and smell
bank of information that can be processed by a computer.
functional health patterns
method for organizing assessment data based on the level of patient function in specific areas.
nursing health history
data collected about a pts present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness
information that can be observed by others; free of feelings, perceptions, and prejudices
open ended question
form of question that prompts pt to answer in more than one or two words
info gathered from pt statements; the pts feelings and perceptions. not verifiable by another except by inference.
act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan
includes active listening prompts such as, "all right, go on, uh huh"
pt experiencing other symptoms along with the primary symptom. ex: nausea accompanied by pain
Review of symptoms ROS
is a systematic approach for collecting the pts self reported data on all body sysmptoms
judgment that is clinically validated by the presence of major defining characteristics
physiological complication that requires the nurse to use nursing and health care provider prescribed interventions to maximize patient outcomes
set of signs and symptoms that are grouped together in logical order
related signs and symptoms or clusters of data that support the ND
study of all factors that may be involved in the development of a disease
formal statement of the disease entity or illness made by the physician or health care provider
formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step during which the pts actual and potential unhealthy responses to an illness or condition are identified.
any condition or event that accompanies or is linked with the pts health care problem
Describes human responses to health conditions/ life processes that may develop in vulnerable pt
is an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion
health promotion nursing diagnosis
a clinical judgment of pt motivation, desire, and readiness to increase well being and actualize human health potential as expressed in their readiness to enhance specific health behaviors.
an approved name of the ND
therapies that require knowledge skill and expertise of multiple health care professionals
process in which the help of a specialist is sought to identify ways to handle problems in pt management or in planning and implementing programs
tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, pathway is used to manage the care of a pt throughout a projected length of stay
process of designing interventions to achieve the goals and outcomes of health care delivery
reason why a specific nursing action was chosen based on supporting literature
the ordering of nursing diagnoses or pt problems using determinations of urgency to establish a preferential order for nursing actiions
a broad statement that describes a desired change in a pts condition or behavior
a measurable criterion to evaluate goal achievement
pt centered goal
reflects a pts highest possible level of wellness and independence in funtion
short term goal
an objective behavior or response that you expect a pt to achieve in a short time usually less than a week
long term goal
objective behavior or response that you expect a pt to achieve over a longer period usually over several days weeks or months
nursing sensitive patient outcome
is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.
independent nursing interventions
actions nurses initiate. pertain to activities of daily living, health education and counseling
dependent nursing interventions
actions that require an order from a doctor
nursing care plan
includes ND, goals and expected outcomes, interventions and evaluations
interdisciplinary care plans
include contributions from all disciplines involved in pt care
any harmful, unintended effect of medication, diagnostic test, or therapeutic intervention
initiation and completion of the nursing actions necessary to help the pt achieve health care goals
instrumental activities of daily living IADL
activities necessary for independence in society beyond eating grooming transferring and toileting. include such skills as shopping preparing meals, banking, and taking medications
any treatment based on clinical judgment and knowledge that a nurse performs to enhance pt outcomes
preventive nursing actions
nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, and third health care
written and approved documents containing rules policies, procedures, regulations, and orders for the conduct of pt care in various stipulated clinical settings
interventions are treatments performed through interactions with pt
interventions are treatments performed away from the pt but on the behalf of the pt or group of pts
clinical practice guideline
systematically developed set of statements that helps nurses and doctors man decisions about appropriate health care for specific clinical situaltions
physical care technique that you use when a pts physiological state is threatened
means that pts and families invest time in carrying out required treatments
determination of the extent to which established pt goals have be achieved
standard of care
minimum level of care accepted to ensure high quality care to pt. standards of care define the types of therapies typically administered to pts with defined problems or needs