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Fundamentals-Nursing Process

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Question
Answer
Nursing process   systematic, rational method of nursing care  
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descision making process   identify purpose, set criteria, weigh criteria, seek alternatives, examine alternatives, project, implement, evaluate  
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Assessing   collect, organize, validate,document data  
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Diagnosing   analyze data, identify risks & strengths, formulate diagnostic statements  
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Planning   Prioritize,formulate goals and outcomes,select interventions, write orders  
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Implementing   reassess,implement interventions,delegate,document  
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Evaluating   compare data to outcomes, draw conclusions, modify care plan  
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subjective data   symptoms only the pt. can verify  
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objective data   signs detectable to observer  
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directive interview   highly structured, elicits specific info  
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nondirective interview   rapport building interview  
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cephalocaudal approach   head to toe approach  
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Maslow's Theory   heirarchy of needs  
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validation   double checking data to confirm accuracy  
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cues   what pt. says or nurse sees  
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inferences   nurses interpretation  
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diagnosis   statement regarding the nature of problem  
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risk factors diagnosis   indicates a problem that could develop  
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wellness diagnosis   readiness for enhancement of wellness  
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possible diagnosis   evidence is incomplete  
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syndrome diagnosis   associated with a cluster of other diagnoses  
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diagnostic 3 part statement   PES  
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Problem   statement of clients response  
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Etiology   factors contributing to probable cause of response  
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Signs and Symptoms   defining characteristics manifested by pt.  
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nursing intervention   any treatment based on clinical judgment that a nurse performs  
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formal care plan   written or computerized guide  
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informal care plan   strategy that exists in the nurses mind  
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standardized care plan   formal plan for all individuals with same etiology  
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individualized care plan   tailored for specific pt.  
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Nursing Care Classification (NOC)   standardized nursing language  
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indicator   concrete observable state of behavior  
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