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Foundations

Chapter 6 Key Terms

TermDefinition
actual nursing diagnosis statement of health problem that a nurse is licensed and competent to treat
assessment evaluation or appraisal of a condition; includes observing, gathering, verifying, and communicating pertinent data, usually information pertaining to the patient
biologic data relating to the facts and events of a person’s life
case management the assignment of a health care provider to oversee the case of an individual patient
clinical pathway multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, high-cost types of cases
collaborative problems actual or potential health problem (complication) that focuses on the pathophysiologic response of the body of which nurses are responsible and accountable for identification and treatment in collaboration with the physician.
cue word, phrase, or symptom that indicates the nature of something perceived. Cues are grouped to assist the nurse in interpretation of data, as in formulating the patient’s plan of care
database large store or bank of information, as in forming the patient’s nursing diagnosis
defining characteristics clinical signs and symptoms that a problem exists
diagnose to identify a disease or condition by a specific evaluation of physical signs, symptoms, history, laboratory tests, and procedures
evaluation the determination made about the extent to which the established outcomes have been achieved in the nursing care plan
goal the purpose to which an effort is directed
implementation the phase of nursing process that includes ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation
managed care a health care system that involves administrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated, and costs are reduced. Health education and preventive medicine are emphasized.
medical diagnosis the identification of a disease or condition by scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures
NANDA-1 North American Nursing Diagnosis Association International
nursing diagnosis a clinical judgment about individual, family, or community response to actual or high-risk (potential) health problems or life processes
nursing interventions activity performed by nurses that should promote the achievement of the desired patient outcome
nursing process systematic method by which nurses plan and provide care for patients
nursing- sensitive patient outcomes the results or outcomes of nursing interventions. Theses outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices
objective data of or pertaining to clinical finding that is observed, palpated, or auscultated. Laboratory findings, as well as radiologic and other studies, are included; observable and measurable signs
outcome description of the specific measurable behavior (outcome criteria) that the patient will be able to exhibit after the nursing interventions
planning in the five-step nursing process, a category of nursing behavior in which a strategy is designed for the achievement of the goals of care for an individual patient, as established in assessing and analyzing
problem any health care condition that requires diagnostic, therapeutic, or educational action
risk nursing diagnosis a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in same or similar situation
standardized language a structured vocabulary that provides nurses with a common means of communication
subjective data symptoms; verbal statements provided by the patient. That which arises from within or is perceived by the individual and related to the examiner
syndrome nursing diagnosis used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances
variance the unexpected event that occurs during the use of a clinical pathway; can be positive or negative
wellness nursing diagnosis a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness
Created by: stjean224