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Health Assessment
Chapter 1 -- Critical Thinking and the Nursing Process
25
Nursing
Undergraduate 3
09/22/2010

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Term
Professional Intuition
Definition
*develops over time as nurses begin to link certain patterns or events to specific patient outcomes
*the novice may need guidance to perceive links intuitively recognized by the experienced nurse
*
Term
What does the science of nursing involve?
Definition
analytical thinking
causation
key factors
possible outcomes
(to a situation)
Term
What scientific principles is the science of nursing based upon?
Definition
physiology
pathophysiology
environmental factors
research data
Term
inference
Definition
speculates, derives, or reasons a specific premise based on information and assumptions obtained from the patient
Term
clarity
Definition
asks if the obtained message or information is clearly understood
Term
accuracy
Definition
asks if the information obtained is accurate and without error
Term
precision
Definition
asks if the information is exact and nonjudgmental
Term
relevance
Definition
asks if all the information connects to the central problem
Term
developing the nursing database
Definition
can establish a baseline for future encounters with the patient as well as serve as a point of comparison should the patient's condition change
Term
subjective data
Definition
usually gathered from the pt during the health history interview
Term
actual nursing diagnoses
Definition
typically problem oriented and describe human responses that have been validated by the nurse
Term
risk nursing diagnoses
Definition
defined as "human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community" they are supported by risk factors that contribute to increased vulnerability
Term
wellness nursing diagnoses
Definition
represent the pt's striving for a higher level of health and wellness. they focus on the strengths of the pt.
Term
chronic nursing diagnoses
Definition
NOT A TYPE OF NURSING DIAGNOSIS! **
Term
Mr. P's "anxiety related to perceived threat of death"
Definition
the human response amenable to nursing intervention as defined by NANDA (North American Nursing Diagnosis Association)
Term
defining characteristics
Definition
signs, symptoms, and statements made by the pt that validate the existence of the actual or wellness nursing diagnosis
Term
Body image disturbance
Definition
possible nursing diagnosis
next would come the "related factors," which would be the origin of the pt's health problem
Term
according to Maslow, which basic needs take priority over all other issues?
Definition
oxygen, water, food
Term
patient outcomes
Definition
indicate the progression towards goal achievement; realistic and measurable pt outcomes are written by the nurse to ensure continuity in pt care
Term
time frames in pt outcomes
Definition
every pt outcome must include a time frame that designates the time by which the pt outcome should be met
Term
Implementation phase
Definition
*the nurse executes the interventions that were devised during the planning phase.
*the time frame of the implementation phase varies from pt to pt and from nursing diagnosis to nursing diagnosis.
*the nurse simultaneously implements the intervention from multiple nursing diagnoses for a pt at any given time.
*it is a dynamic process; the nurse is continually interacting with pt, family, and other health care colleagues, changing the plan of care based on the continuous flow of information
Term
evaluation phase
Definition
the nurse, in conjunction with the pt and family, evaluates the status of the plan of care
Term
critical pathways
Definition
maps that show the outcome of predetermined pt goals over a period of time; for ex, they state what activity the pt should be capable of performing daily based on the pt's diagnosis-related group (DRG)
Term
SOAPIER
Definition
S--subjective data
O--objective data (physical exam)
A--analysis of data (nursing diagnosis)
P--plan of care
I--intervention/implementation
E--evaluation
R--revision of the plan
Term
nursing care plan
Definition
combines the elements of the nursing process to document the progress of pt care in a standard fashion.
nursing care plans serve as means of communicating pt progress with other health care colleagues and ensuring continuity of care among the nursing staff.
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