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Fundamentals Ch.9
Nursing Process Key Terms
| Term | Definition |
|---|---|
| assessment | First step of the nursing process; activities required in the first step are data collection, data validation, data sorting, and data documentation. The purpose is to gather information for health problem identification. |
| back-channeling | Active listening technique that prompts a respondent to continue telling a story or describing a situation. Involves use of phrases such as "go on", "uh huh", and "tell me more". |
| clinical practice guideline | A systematically developed set of statements that helps nurses and other health care providers make decisions about appropriate health care for specific clinical situations. |
| closed-ended question | A form of question that limits a respondent's answer to one or two words. |
| collaborative interventions | Therapies that require the knowledge, skill, and expertise of multiple health care professionals. |
| collaborative problem | Physiological complication that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes. |
| concept map | A care-planning tool that assists in critical thinking and forming associations between a patient's nursing diagnoses and interventions. |
| consultation | Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in the planning and implementing of programs. |
| counseling | A problem-solving method used to help patients recognize and manage stress and to enhance interpersonal relationships; it helps patients examine alternatives and decide which choices are most helpful and appropriate. |
| critical pathways | Used in managed care to incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay. |
| cue | Information that a nurse acquires through hearing, visual observations, touch and smell. |
| data analysis | Logical examination of and professional judgment about patient assessment data; used in the diagnostic process to derive a nursing diagnosis |
| data cluster | A set of signs or symptoms that are grouped together in logical order. |
| database | Store or bank of information, especially in a form that can be processed by computer. |
| defining characteristic | Related signs and symptoms or clusters of data that support the nursing diagnosis. |
| dependent nursing interventions | Actions that require an order from a physician or another health care professional. |
| direct care interventions | Treatments performed through interaction with the patient. For example, a patient may require medication administration, insertion of an intravenous infusion, or counseling during a time of grief. |
| etiology | Study of all factors that may be involved in the development of a disease. |
| evaluation | determination of the extent to which established patient goals have been achieved. |
| expected outcome | Expected conditions of a patient at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education. |
| functional health patterns | Method for organizing assessment data based on the level of patient function in specific areas, for example, mobility. |
| goal | Desired results of nursing actions, set realistically by the nurse and patient as part of the planning stage of the nursing process. |
| health history | 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. |
| implementation | Initiation and completion of the nursing actions necessary to help the patient achieve health care goals. |
| independent nursing intervention | Actions that nurses initiate. |
| indirect care interventions | Treatments performed away from the patient but on behalf of the patient or group of patients. |
| inference | (1) A judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows. |
| instrumental activities of daily living | Activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting and include such skills as shopping, preparing meals, banking, and taking medications. |
| interdisciplinary care plans | Contributions from all disciplines are involved in patient care. |
| medical diagnosis | Formal statement of the disease entity or illness made by the physician or health care provider. |
| NANDA International (NANDA-I) | North American Nursing Diagnosis Association, organized in 1973, which formally identifies, develops, and classifies nursing diagnoses. |
| nursing diagnosis | Formal statement of an actual or potential health problem that nurses can legally and independently treat. The 2nd step of the nursing process, in which the patient's actual & potential unhealthy responses to an illness or condition are identified. |
| nursing diagnosis process | Flows from the assessment process and includes data clustering, interpreting and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem. |
| nursing intervention | Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes. |
| nursing process | Systematic problem-solving method by which nurses individualize care for each patient. A- assessment, D- diagnosis, P- planning, I- implementation, E- evaluation |
| nursing-sensitive outcome | Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient's symptoms, functional status, safety, psychological distress, or costs. |
| objective data | Information that can be observed by others; free of feelings, perceptions, prejudices. |
| open-ended questions | A form of question that prompts a respondent to answer in more than one or two words. |
| planning | Process of designing interventions to achieve the goals and outcomes of health care delivery. |
| related factor | Any condition or event that accompanies or is linked with the patient's health care problem. |
| scientific rationale | Reason, based on supporting literature, why a specific nursing action was chosen. |
| standard of care | Minimum level of care accepted to ensure high-quality care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs. |
| standing order | Written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings. |
| subjective data | Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference. |
| validation | Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan. |
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