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Nursing Proc/ Pharm
The Nursing Process and Pharmacology
| Term | Definition |
|---|---|
| Nursing process | The foundation for the clinical practice of nursing. |
| Nursing classification systems | Systems designed to provide a standardized language for reporting and analysis of nursing care delivery that has been individualized for the patient. |
| Assessment | An ongoing process that starts with the admission of the patient and continues until the patient is discharged from care. |
| Nursing diagnosis | A diagnosis that usually refers to the patient's ability to function in activities of daily living in relation to the impairment induced by the medical diagnosis. |
| Defining characteristics | Manifestations or signs and symptoms. |
| Medical diagnosis | A statement of the patient's alterations in structure and function that results in an identification of a disease or disorder that is impairing normal physiologic function. |
| Collaborative problem | Physiologic complications that nurses monitor, but for which nurses cannot independently initiate definitive treatment. |
| Focused assessment | The process of collecting additional data specific to a patient or family that would validate a suggested problem or nursing diagnosis. |
| Planning | The third phase of the five-step nursing process.(1) priority setting; (2) the development of measurable goal and outcome statements; (3) the formulation of nursing interventions; and (4) the formulation of anticipated therapeutic outcomes. |
| Nursing care plan | The written or computer-generated document that evolves from planning. |
| Critical pathways | A standardized care plan derived from the "best practice" patterns, enabling the nurse to develop a treatment plan that sequences detailed clinical interventions to be performed over a projected amount of time for a specific case type or disease process. |
| Core measures | Measures of care that are tracked to show how hospitals &healthcare providers use the care recommendations identified by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia |
| Evidence-based medicine or practice | The application of data from scientific research to make clinical decisions about the care of individual patients. A method of improving patient outcomes by implementing best practices that have evolved from scientific studies. |
| Priority setting | Prioritizing an individual patient's needs by organizing them in relation to their direct effects on the maintenance of homeostasis. |
| Measurable goal statement | Established and written short- and long-term patient goals to promote the therapeutic regimen and course of treatment. |
| Patient goals | Established short- and long-term patient goals to promote the therapeutic regimen and course of treatment. |
| Implementation | The fourth phase of the nursing process; consists of carrying out the established plan of care. |
| Nursing interventions | The actual process of performing the established plan of care. |
| Nursing actions | Suggested by the etiology of the problems identified in the nursing diagnoses. They are used to implement plans. |
| Dependent actions | Nursing actions the nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health. |
| Interdependent actions | Nursing actions the nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health. |
| Independent actions | Nursing actions not prescribed by a healthcare provider that a nurse can provide by virtue of education and licensure attained. |
| Nursing orders | Statement describing how specific actions will be implemented for an individual patient. |
| Anticipated therapeutic statements | Statements documenting the effectiveness of patient care delivered. |
| Expected outcome statements | Statements documenting the effectiveness of patient care delivered. |
| Drug history | A list of all prescription and over-the-counter medications, and herbal products a patient is taking. For each medication, note the name, dose, schedule, and duration of use. |
| Primary source | The patient is the main source of information. |
| Subjective data | Information provided by the patient. |
| Objective data | Information gained from observations that the nurse makes using physiologic parameters. |
| Secondary sources | Information sources other than the patient, such as relatives, medical records, laboratory reports, or other healthcare professionals. |
| Tertiary sources | Information sources such as a literature search. |
| Drug monographs | A statement that specifies the kinds and amounts of ingredients a drug or class of drugs may contain, the directions for the drug's use, the conditions in which it may be used, and the contraindications to its use. |
| Therapeutic intent | Determining why the drug was prescribed and what symptoms will be relieved. Included in the planning part of the nursing process |
Created by:
Jessica Venyke
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