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Fundamentals Ch.9

Nursing Process Key Terms

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.