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Ch 2 Fund Vocab

Words to know from Chapter 2 of Fundamentals.

TermDefinition
Assessment systematic collection of information.
Collaborative problem physiologic complication whose treatment requires both nurse- and physician-prescribed interventions
Concept mapping organizing information in a graphic or pictorial form.
Critical thinking process of objective reasoning; analyzing facts to reach a valid conclusion.
Database assessment initial information about the client's physical, emotional, social, and spiritual health.
Diagnosis identification of health-related problems.
Evaluation process of determining whether a goal has been reached.
Focus assessment information that provides more details about specific problems.
Functional assessment determining a person's ability to perform self-care task.
Goals expected or desired outcome.
Health promotion diagnosis a concern with which a healthy person desires nursing assistance to maintain or achieve a higher level of wellness.
Implementation carrying out a plan of care.
Long-term goals desirable outcomes that take weeks or months to accomplish.
NANDA International the authoritative organization for developing and approving nursing diagnoses.
Nursing care plan written list of the client's problems, goals, and nursing orders for client care.
Nursing diagnosis health problem that can be prevented, reduced, or resolved through independent nursing measures.
Nursing orders directions for a client's nursing care.
Nursing process organized sequence of problem solving steps: assessment, diagnosis, planning, implementation, and evaluation
Objective data facts that are observable and measurable.
Outcome criteria specific evidence for each nursing diagnosis that a client's problem is trending toward resolution or has been resolved.
Planning process of prioritizing nursing diagnoses and collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions, and documenting the plan for care.
Problem- focused diagnosis a problem that currently exists.
Risk diagnosis a problem the client is uniquely at risk for developing.
Short-term goals outcomes that can be met in a few days to a week.
Signs objective data; information that is observable and measurable.
Standards for care policies that ensure quality client care.
Subjective data information that only the client feels and can describe.
Symptoms subjective data; that which only the client can identify.
Syndrome diagnosis cluster of problems that is present due to an event or situation.
The Joint Commission a not-for-profit organization that accredits health care organizations in the US.
Created by: Jessica Venyke
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