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Nursing Proc/ Pharm

The Nursing Process and Pharmacology

TermDefinition
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