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| A Cognitive process that includes creativity, problem solving & decision making |
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| Making generalizations from specific data |
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| Making specific observations from a generalization |
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| Obtaining information that clarifies the nature of a problem & suggests possible solutions |
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| The process of establishing criteria by which alternative courses of action are developed & selected |
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| A systematic rational method of planning & providing nursing care |
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| The process of collecting, organizing, validating, & recording data about a client's health status |
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| Ongoing process that involves assessing, establishing goals, developing a plan of action, deteries deadlines, describes how outcomes are to be achieved & evaluated |
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| Phase of nursing process in which the nursing care plan is put into action |
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| Planned, ongoing, purposeful activity in which clients & health care professionals compare expected outcomes to actual outcomes |
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| Highly structured interview that uses closed ended questions to elicit specific information |
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| Interview using open ended questions & empathetic responses to build rapport & learn client concerns |
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| Questions that specify only a broad topic & invite clients to explore thoughts & feelings about the topic |
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| Set of questions one can apply to a particular situation or idea to determine essential information & ideas & discard superfluous information & ideas |
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| Nurse's clinical judgement about responses to actual & potential health problems to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable |
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| Clinical judgement that a problem does not exist, but the presence of risk factors indicates a problem is likely to develop unless nurse intervenes |
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| Describe human responses to levels of wellness that have a readiness for enhancement |
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| One in which evidence about a health problem is incomplete or unclear |
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| Diagnosis that is associated with a clster of other diagnoses |
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| Title used in writing a nursing diagnosis taken from the NANDA standardized taxonomy of terms |
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| Client signs & symptoms that must be present to validate a nursing diagnosis |
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| Casual relationship between a problem & its related factors |
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| North American Nursing Diagnosisn Association |
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| Process of anticipating & planning for client needs after discharge |
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| The skills of learning commonly possessed by members of a profession |
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| Predetermined & preprinted plan specifying the procedure to be followed in a particular situation |
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| Rules to govern the handling of frequently occuring situations |
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| Formal plan that specifies the nursing care for groups of clients with common needs |
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| Nursing Outcomes Classification (NOC) |
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| A taxonomy for describing client outcomes that respond to nursing interventions |
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| Process of establishing a preferential order for nursing interventions |
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| Desired outcomes- describe in terms of observable client responses what the hopes to achieve by implementing nursing interventions |
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| Goals- describe in terms of observable client responses what the nurse hopes to achieve by implementing nursing intervention |
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| Any treatment that a nurse performs to enhance client outcomes, based on clinical judgement & knowledge |
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| Intellectual skills that include problem-solving, decision-making, critical thinking & creativity |
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| All verbal & nonverbal activities people use when communicating directly with one another |
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| Hands-on skills such as those required ro manipulate equipment or administer injections |
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| Transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome |
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| An ongoing systematic process designed to evaluate & promote excellence in providing health care |
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| Any information a subject relates will not be made public or available to others without the subject's consent |
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| Source-oriented clinical record |
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| A record in which each person/department makes notations in a separate area of the record |
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| Problem-oriented medical record |
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| Client data that is recorded & arranged according to the client's problems |
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| Method of charting that uses key words or foci to describe what is happening to the client |
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| Acronym for a charting method that follows a recording sequence of problem, intervention, & evaluation of the effectiveness of interventions |
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| Documentation system in which only significant findings or exceptions to norms are recorded |
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| Computer-based client records |
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| Electronic client data retrievable by caregivers & other persons who require the data |
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| Method for delivering nursing care in which the nurse is resposible for a caseload of clients across the health care continuum |
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| trade name for a method using a series of cards to organize & record client data & instructions for daily care |
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| Chart entries made by all health professionals involved in patient care for the purpose of describing client problems, treatments, & progress toward desired outcomes |
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| A record of the progress of data, often charted in graph form |
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| Report given to nurses on the next shift |
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