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Health Safety
Essentials of Nursing Care
Term | Definition |
---|---|
Nursing | protection, promotion, and optimization of health & abilities, prevention of illness/injury |
Nursing Process | Assessment, Dx, Outcomes Identification, Planning, Implementation, and Evaluation |
Assessment | systematic ongoing collection of comprehension data relevant to patients health |
DX | clinical judgment about the health care consumers response to actual or potential health conditions or needs |
Outcomes identification | identification of expected care outcomes that are individualized according to the pts presenting needs or dx |
Implementation | Activities: providing, monitoring, delegating, coordinating, teaching, and counseling |
Standard 5a Coordination of care | Involves organizing and documenting the plan |
Standard 5b: Health teaching and health promotion | Healthy lifestyles, risk-reducing behavior, developmental needs, ADL, an preventative self-care |
Evaluation | process of determining the progress toward attainment of expected outcomes, including the effectiveness of care |
Assessment data | Initially collected upon admission of a patient to a hospital |
Focused health data assessment | performing selected portion of an H&P, pt c/o new or changed sx, new or changed sx, |
Emergency nursing assessment | data collection process which occurring during a life-threatening situation |
time-lapsed nursing assessment | repeated assessment obtained to compare data collected at one or more pts in time with baseline |
Primary data | nurse derives directly from interaction with the patient |
Secondary data | data derived from all other sources |
Patient database | Sum of all primary and secondary information collected on any one patient |
Nursing Dx | conclusion drawn from an analysis of the assessment data, clinical inferences mad on the basis of assessment, or clinical judgments that the nurse makes after assessing |
Risk factors | variables that increase a pts vulnerability to developing an actual nursing dx. |
NANDA international Nursing Diagnoses: Definitions and Classification 2012-2014 | Identifies four major types of nursing Dx; Actual, health promotion, risk, and syndrome diagnoses |
Actual DX: | human response to a health condition or life process that is happening at the present time |
Health promotion DX: | clinical judgment that increases the pts motivation to enhance specific health supporting behavior (individuals, families, groups, or communities). |
Risk DX: | refers to a dx that, given the right conditions, has a high probability or occurring in a vulnerable person, family, group , or community. |
Syndrome diagnosis | describes a clinical judgment that uses at least two nursing diagnoses |
Maslow's hierarchy of needs | Physical, Safety, Love, Self-esteem, Self-Actualization needs |
Policies | written instructions designed to address a commonly occurring problem in a n institutionally approved manner |
Protocols | institutionally approved preprinted instructions governing interventions or actions to be taken in the care of groups of health care consumers with particular problems |
Structure | defined as the setting of the environment in which the care is given |
Process | refers to the appropriateness of the care given and whether policies and procedures were followed to maximize patient safety, minimize medication error, minimize infectious contamination, and ensure that pts and families feel welcome |
Outcome evaluation | examines such quality indicators as number of pt falls, number of new pressure ulcers formed, number of postoperative wound infections, and number of tube-fed pat developing aspiration pneumonia |
Terminal Evaluation | evaluation of outcomes also occurs prior to discharge or prior to a case being closed |