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Health Safety

Essentials of Nursing Care

TermDefinition
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
Created by: 1315933871