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VNPT51 CH.5 Terms
VNPT51 Chapter 5 Nursing process and Critical Thinking-MB
| Term | Definition |
|---|---|
| actual nursing diagnosis | a clinical judgement about human experiences, responses to health conditions, and life processes that exist in an individual, family, or community |
| Asessment | a systematic, dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and health care providers, collects and analyzes data |
| Biographic data | provide information about the facts or events in a person's life |
| case management | encompassing planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient; allows for continuity of care because one person coordinates the plan of care for an individual patient |
| clinical pathway | a multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high-volume, high-cost types of cases while providing for optimal patient outcomes and maximized clinical efficiency |
| collaborative problems | health-related problems that the nurse anticipates based on the condition or diagnosis of a patient; prevention uses both physician-prescribed interventions and nursing-prescribed interventions |
| cue | a piece or pieces of data that often indicates that an actual or potential problem has occurred or will occur |
| database | a completed nursing health history and a physical examination allow the nurse to establish |
| defining characteristics | the clinical cues, signs, and symptoms that furnish evidence that the problem exists; often prefaced with "as evidenced by" |
| diagnose | to identify the type and cause of a health condition |
| evaluation | a determination made about the extent to which the established outcomes have been achieved |
| goal | a well-written patient-centered |
| implementation | the nurse and other members of the team put the established plan into action to promote outcome achievement; plan must be implemented in a timely and safe manner |
| managed care | health care systems that have control over primary health care services and attempt to trim down health care costs by reducing unnecessary or overlapping services; with an emphasis placed on health promotion, education, and preventative medicine |
| medical diagnosis | the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records, and patient history |
| NANDA-I | The North America Nursing Diagnosis Association was created, to reflect nursing diagnosis terminology that is used across the world. |
| nursing diagnosis | this provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability |
| nursing interventions | those activities that promote the achievement of the desired patient outcome |
| nursing process | a systematic process by which nurses plan and provide care for patients |
| nursing-sensitive patient outcomes | outcomes that are responsive to nursing care |
| objective data | observable and measurable signs of health issues |
| outcome | 2. establish the measuring standard that is used to evaluate the effectiveness of the nursing interventions |
| planning | priorities of care are established and nursing interventions are chosen to best address the nursing diagnosis; communicated via care plan; must work with patient and significant others in choosing appropriate interventions |
| risk nursing diagnosis | a clinical judgment that describes human responses to health conditions and life processes that may develop in a vulnerable individual, family, and/or community; supported by risk factors that contribute to increased vulnerability |
| standardized language | fosters communication regarding aspects of patient care. |
| subjective data | information provided by the patient about symptoms that cannot be seen or measured by another person |
| syndrome nursing diagnosis | a clinical judgment describing a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions |
| variance | when a patient does not achieve the projected outcome |
| wellness nursing diagnosis | a clinical judgment about a person's family's or community's motivation,desire to increase wellbeing and human health potential as expressed, to enhance specific health behaviors |
Created by:
barragan_93230
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