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Week 1
Terminology 1
| Term | Definition |
|---|---|
| Pathology | The science of the causes and effects of diseases, especially the branch of medicine that deals with the laboratory examination of samples of body tissue for diagnostic or forensic purposes. |
| Pathogenesis | The manner of development of a disease. |
| Clinical Judgement | Clinical judgement refers to ways nurses come to understand the problems, issues, or concerns of clients/patients, to attend to salient information and to respond in concern and involved ways. |
| Planning | The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. |
| Objective Data | Objective data are observable and measurable data (signs) obtained through observation, physical examination and laboratory and diagnostic testing. |
| Client Health History | Health history a holistic assessment of all factors affecting a patient's health status including information about social, cultural, familial an economic aspects of the patient's life as well as any other component of the patient's life style that affect |
| General survey | The general survey consists of a patient's age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build rapport with them that can ease anxiety and lead to a trusting relationship |
| Percussion | Percussion is a method of tapping body parts with fingers, hands or small instruments as part of a physical examination. It is done to determine: the size, consistency, and borders of body organs. |
| Collaborative Problem | A collaborative problem is a potential physiologic complication that nurses monitor to detect onset or change in status and manage using medically-prescribed and nursing-prescribed interventions to prevent or minimize the complications. |
| Dependent nursing intervention | Dependent nursing interventions are those that require guidance or supervision from a physician or other medical professional. Interdependent nursing interventions are those that nurses perform as part of a collaborative team of medical professionals work |
| Preventative error | It involves alerting a patient/client when they are making an error, with the intention to make it easy for them to do whatever it is they are doing without making a mistake. |
| Sentinel Event | A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event. |
| Physiology | Anatomy and physiology is a course that describes the structure and operation of one's individual body. The course concentrates on how one's individual system performs together to operate properly |
| Clinical Manifestations | Clinical manifestations that can be either objective when observed by a physician, or subjective when perceived by the patient. |
| Nursing Process | The nursing process is a scientific five-step approach that nurses use to safeguard the levels of care that patients receive. Assessment, Diagnosis, planning, Implementation and Evaluation also known as ADPIE |
| Implementation | The process of putting a decision or plan into effect. |
| Primary Source | A primary source is a client and usually the nurse's best source of information |
| Review of Systems | The review of systems is a systematic method for collecting data on all body systems. Not all questions in each system may be covered in every history. |
| H2T Assessment | |
| Auscultation | Auscultation involves listening to sounds the body makes to detect variations from normal. Some sounds can be heard without assistance, but most will require a stethoscope. |
| Diagnostic Label | The diagnostic label is the name of the nursing diagnostic as approved by NANDA International. It describes the essence of a client's response to health conditions in as few words as possible. |
| Cultural Safety | cultural safety is about acknowledging the barriers to clinical effectiveness arising from the inherent power imbalance between provider and patient. This concept rejects the notion that health care providers should focus on learning cultural customs and |
| Communication Error | In faxing, an error that occurs during sending or receiving information. |
| Pathophysiology | The disorder physiological process associated with disease or injury. |
| Treatment Implications | Developing pharmacotherapies to treat a disease or addiction with associated health problems. |
| Assessment | A systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic and life-style factors as well. |
| Evaluation | Evaluation is the final step in the nursing process, yet it directs the nurse back to the first step of assessment. |
| Secondary Source | A secondary source is family and significant other that are the most knowledgeable sources of information for infants and children, critically ill adults and mentally challenged, disoriented or unconscious clients. |
| Physical Assessment | A comprehensive physical examination involves the use of five skills. Inspection, palpation, percussion, auscultation and olfaction. |
| Inspection | It is the visual examination that is, assessing by using the sense of sight. |
| Data Verification | Data verification consists of reviewing the data for inconsistencies or omissions, observing nonverbal behavior to confirm or contradict a client's perceptions, comparing data with norms, and rechecking confirming grossly abnormal findings. |
| Prioritization | Prioritization is the activity that arranges items or activities in order of importance relative to each other. In context of medical evaluation it is the establishment of the importance r the urgency of actions that are necessary to preserve the welfare |
| Diagnostic Error | Errors occur in the nursing diagnostic process during data collection, interpretation and analysis and clustering and in statement if the diagnosis. |
| Adverse Event | An event, preventable or nonpreventable that caused harm to a patient as a result of medical care. |
Created by:
Shawn06
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