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VNPT51 CH.5 Terms

VNPT51 Chapter 5 Nursing process and Critical Thinking-MB

TermDefinition
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