A systematic method for nurses to plan and implement client care to achieve desired outcomes.
What is assessment?
The careful observation and evaluation of a client's health status.
What is the client database?
The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies.
What is the nursing diagnosis?
The second phase of the nursing process, in which the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve.
What are actual nursing diagnoses?
They identify existing problems.
What are health promotion nursing diagnoses?
They reflect clinical judgment of a client's motivation to increase well-being and enhance health-seeking behaviors.
What are the three parts of nursing diagnostic statements?
The name or label of the problem,
the cause of the problem,
the signs and symptoms, or data, that indicate the problem.
What is risk nursing diagnosis?
A problem that the client is at high risk for developing.
What is wellness diagnosis?
No problem exists; the client desires a higher level of wellness.
What is syndrome diagnosis?
Used when the diagnosis is associated with a cluster of other diagnosis.
What are collaborative problems ?
A problem that is monitored and managed by the nurse using physician prescribed and nursing prescribed interventions.
Define planning in the nurses process.
Setting priorities, defining expected outcomes, determining specific nursing interventions, and recording the plan of care.
Name the levels of Maslow.
Physiologic needs (first level)
safety and security needs (second level)
love and belonging needs (third level)
esteem and self esteem needs (fourth level)
self actualization needs (fifth level)
What are expected outcomes?
Outcomes are specific and realistic, so the client can obtain them and not become frustrated, and measurable so the nurse can reliably determine to what extent the client is meeting the goals.
What are interventions?
Actions for achieving the outcome.
What are nursing orders?
They are specific nursing directions so that all healthcare team members understand exactly what to do for the client.
What is implementation?
Carrying out the written plan of care, performing the interventions, monitoring the client status, and assessing and reassessing the client before, during, and after treatments.
What are the five functions of documentation?
shows trends and patterns in client status
creates a legal document
supplies validation for reimbursement
provides a foundation for evaluation, research, and quality improvement.
What is the evaluation phase?
The assessment and review of the quality and suitability of caregiving and the clients responses to that care.
What is critical thinking?
Intentional, contemplative, and outcome directed thinking.
Written rules for conduct and action.
Moral principles and values that guide the behavior of honorable people
Define constitutional law
Laws based on the Constitution that protect nurses basic rights
Define statutory law
A law that any local, state, or federal legislative body enacts
What does the nurse practice act do?
It defines nursing practice and sets standards for nurses in each state.
Define administrative law
The rules and regulations that concerned the health, welfare, and safety of federal and state citizens.
Define board of nursing
The administrative agency with the authority to regulate the nurse practice act
Define common law
Laws based on earlier court decisions, judgments and decrees
Define criminal law
Laws that concern offenses that violate the publics welfare
Define civil law
Laws that apply to disputes that arise between individual citizens
Define tort law
The body of law that governs breaches of duty owed by one person to another
An expected action based on moral or legal obligations
An injury that occurred because of another person's intentional or unintentional actions, or failure to act
A deliberate and willful act that infringes on another person's rights or property
An act that involves a threat or attempt to do bodily harm
Actual physical contact with another person without that person's consent
Win healthcare workers physically or chemically restrain an individual from leaving a healthcare institution
An act that harms a persons reputation and good name
Situations that resulted in injuries, although the person responsible did not mean to cause any harm
The failure to act as a reasonable person would have acted in a similar situation
Defined as professional negligence. It refers to harm that results from a licensed person actions or lack of action
Standards of practice
Guidelines that the nursing profession establishes for clinical decision-making
What are the essential elements of malpractice?
Harm to an individual
duty of a professional toward an individual
breach of duty by the professional
breach of duty as the cause of harm
Good Samaritan law
Provides legal immunity for rescuers who provide first aid in an emergency to accident victims. Nurses are still held to a higher standard of care.
Statute of limitations
The designated time in which a person can file a lawsuit
The process of identifying and then reducing the cost of anticipated losses
Identifies the nature of an incident (who, what, where, and when), witnesses, what actions were taken at the time, and the client's condition
A handwritten, personal account of an incident made at the time of occurrence and updated as needed
The voluntary permission granted by a client, or the clients assigned medical proxy
Legal documents that allow for clients to determine in advance their wishes regarding life-sustaining treatment and other medical care
A document that states the clients wishes regarding healthcare if he or she is terminally ill
Medical durable power of attorney
A person designated by the client to make healthcare decisions for their client if he or she is no longer competent or able to make these decisions.
And outcome oriented approach for decision-making, i.e. "The end justifies the means"
An approach that states that duty is equally important as the consequences
Freedoms or actions to which individuals have a just moral or legal claim
The belief that individuals find most meaningful
Safeguarding clients rights and supporting their interests
The duty to tell the truth
And the duty to do no harm to the client
Define verbal communication
Communication that uses words. It includes speaking, reading, and writing.
An activity that includes attending to and becoming fully involved and what the client says
It refers to vocals sounds (not actually words) that communicate a message
The use of space when communicating
intimate -- -- within 6 inches
personal -- -- 6 inches to 4 feet
social -- -- 4 to 12 feet
public -- -- 12 or more feet
Define comfort zone
The area that when intruded on does not create anxiety
Refers to using verbal and nonverbal communication to promote a person's physical and emotional well-being.
Acquire specific information
Open ended question
Encourages the client to elaborate
An inability to utilize verbal language skills
The manner in which a person best comprehends new information
Processes information best by listening to or reading facts and descriptions
Learns best when presented with information that appeals to his or her feelings, beliefs, and values
Psycho motor learner
Prefers to learn by doing
The skills and concepts that the client and family must acquire to restore, maintain, or promote health
A person's intellectual ability to understand, remember, and apply new information
The desire to acquire new information
Refers to the optimal time for learning
Complementary and alternative medicine
Therapy used in addition to conventional medical treatment
Therapy used instead of conventional medical treatment
Combining conventional medicine with complimentary or alternative therapy
Based on spiritual practices that developed among Tibetan monks using nature to develop a strong body, clear mind, and tranquil spirit.
Proposes that health is the outcome of balancing Yin and Yang that must remain equalize to maintain life's energy force
Native American medicine
Views disease as resulting from this harmony with mother Earth, possession by an evil spirit, or violation of a taboo.
Techniques that rely on the power of the brain, emotions, social interactions, and spiritual factors to alter body functions or symptoms
Use natural products such as dietary supplements, aromatherapy, and animal derived extracts like bee venom
Micro organisms that exert beneficial health effects which can lower the frequency or duration of diarrhea
Non-digestible food ingredients such as dietary fiber that beneficially stimulate or inhibit bacteria in the colon
The medicinal use of bee venom
Manual pressure is applied to the feet and hands
Exercises to integrate body and mind
Promotes healing using electricity, magnets, or both
Treatment that reduces physical disk comfort but does not alter a disease's progression
Care for the caregiver, to provide for periodic relief, during periods of extended home health care
A facility for the care of terminally ill clients, who can live out their final days with comfort, dignity, and meaningfulness
Waiting for permission phenomenon
Some clients seem to forestall dying when they feel that their loved ones are not yet prepared to deal with their death.
The situation in which a person almost dies but is resuscitated.
Nearing death awareness
A phenomenon characterized by a dying clients premonition of the approximate time or date of death.
This occurs before death often when the dying client and family begin to consider the impact of their potential loss.