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Ch 2 Fund Vocab
Words to know from Chapter 2 of Fundamentals.
Term | Definition |
---|---|
Assessment | systematic collection of information. |
Collaborative problem | physiologic complication whose treatment requires both nurse- and physician-prescribed interventions |
Concept mapping | organizing information in a graphic or pictorial form. |
Critical thinking | process of objective reasoning; analyzing facts to reach a valid conclusion. |
Database assessment | initial information about the client's physical, emotional, social, and spiritual health. |
Diagnosis | identification of health-related problems. |
Evaluation | process of determining whether a goal has been reached. |
Focus assessment | information that provides more details about specific problems. |
Functional assessment | determining a person's ability to perform self-care task. |
Goals | expected or desired outcome. |
Health promotion diagnosis | a concern with which a healthy person desires nursing assistance to maintain or achieve a higher level of wellness. |
Implementation | carrying out a plan of care. |
Long-term goals | desirable outcomes that take weeks or months to accomplish. |
NANDA International | the authoritative organization for developing and approving nursing diagnoses. |
Nursing care plan | written list of the client's problems, goals, and nursing orders for client care. |
Nursing diagnosis | health problem that can be prevented, reduced, or resolved through independent nursing measures. |
Nursing orders | directions for a client's nursing care. |
Nursing process | organized sequence of problem solving steps: assessment, diagnosis, planning, implementation, and evaluation |
Objective data | facts that are observable and measurable. |
Outcome criteria | specific evidence for each nursing diagnosis that a client's problem is trending toward resolution or has been resolved. |
Planning | process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan for care. |
Problem- focused diagnosis | a problem that currently exists. |
Risk diagnosis | a problem the client is uniquely at risk for developing. |
Short-term goals | outcomes that can be met in a few days to a week. |
Signs | objective data; information that is observable and measurable. |
Standards for care | policies that ensure quality client care. |
Subjective data | information that only the client feels and can describe. |
Symptoms | subjective data; that which only the client can identify. |
Syndrome diagnosis | cluster of problems that is present due to an event or situation. |
The Joint Commission | a not-for-profit organization that accredits health care organizations in the US. |