Nursing Process Key Terms
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| assessment | First step of the nursing process; activities required in the first step are data collection, data validation, data sorting, and data documentation. The purpose is to gather information for health problem identification.
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| back-channeling | Active listening technique that prompts a respondent to continue telling a story or describing a situation. Involves use of phrases such as "go on", "uh huh", and "tell me more".
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| clinical practice guideline | A systematically developed set of statements that helps nurses and other health care providers make decisions about appropriate health care for specific clinical situations.
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| closed-ended question | A form of question that limits a respondent's answer to one or two words.
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| collaborative interventions | Therapies that require the knowledge, skill, and expertise of multiple health care professionals.
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| collaborative problem | Physiological complication that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes.
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| concept map | A care-planning tool that assists in critical thinking and forming associations between a patient's nursing diagnoses and interventions.
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| consultation | Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in the planning and implementing of programs.
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| counseling | A problem-solving method used to help patients recognize and manage stress and to enhance interpersonal relationships; it helps patients examine alternatives and decide which choices are most helpful and appropriate.
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| critical pathways | Used in managed care to incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay.
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| cue | Information that a nurse acquires through hearing, visual observations, touch and smell.
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| data analysis | Logical examination of and professional judgment about patient assessment data; used in the diagnostic process to derive a nursing diagnosis
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| data cluster | A set of signs or symptoms that are grouped together in logical order.
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| database | Store or bank of information, especially in a form that can be processed by computer.
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| defining characteristic | Related signs and symptoms or clusters of data that support the nursing diagnosis.
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| dependent nursing interventions | Actions that require an order from a physician or another health care professional.
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| direct care interventions | Treatments performed through interaction with the patient. For example, a patient may require medication administration, insertion of an intravenous infusion, or counseling during a time of grief.
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| etiology | Study of all factors that may be involved in the development of a disease.
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| evaluation | determination of the extent to which established patient goals have been achieved.
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| expected outcome | Expected conditions of a patient at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education.
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| functional health patterns | Method for organizing assessment data based on the level of patient function in specific areas, for example, mobility.
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| goal | Desired results of nursing actions, set realistically by the nurse and patient as part of the planning stage of the nursing process.
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| health history | Information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system.
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| implementation | Initiation and completion of the nursing actions necessary to help the patient achieve health care goals.
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| independent nursing intervention | Actions that nurses initiate.
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| indirect care interventions | Treatments performed away from the patient but on behalf of the patient or group of patients.
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| inference | (1) A judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows.
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| instrumental activities of daily living | Activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting and include such skills as shopping, preparing meals, banking, and taking medications.
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| interdisciplinary care plans | Contributions from all disciplines are involved in patient care.
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| medical diagnosis | Formal statement of the disease entity or illness made by the physician or health care provider.
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| NANDA International (NANDA-I) | North American Nursing Diagnosis Association, organized in 1973, which formally identifies, develops, and classifies nursing diagnoses.
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| nursing diagnosis | Formal statement of an actual or potential health problem that nurses can legally and independently treat. The 2nd step of the nursing process, in which the patient's actual & potential unhealthy responses to an illness or condition are identified.
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| nursing diagnosis process | Flows from the assessment process and includes data clustering, interpreting and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem.
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| nursing intervention | Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes.
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| nursing process | Systematic problem-solving method by which nurses individualize care for each patient. A- assessment, D- diagnosis, P- planning, I- implementation, E- evaluation
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| nursing-sensitive outcome | Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient's symptoms, functional status, safety, psychological distress, or costs.
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| objective data | Information that can be observed by others; free of feelings, perceptions, prejudices.
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| open-ended questions | A form of question that prompts a respondent to answer in more than one or two words.
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| planning | Process of designing interventions to achieve the goals and outcomes of health care delivery.
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| related factor | Any condition or event that accompanies or is linked with the patient's health care problem.
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| scientific rationale | Reason, based on supporting literature, why a specific nursing action was chosen.
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| standard of care | Minimum level of care accepted to ensure high-quality care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs.
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| standing order | Written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings.
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| subjective data | Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference.
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| validation | Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.
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