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fund test
ch. 5 and 6
38
Other
Undergraduate 1
02/18/2009

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Term
the nursing process is
Definition
a framework on which to organize individualized nursing care
Term
another term for subjective data is
Definition
symptoms, which cant be oserved or measured-must come from pt
Term
objective data is
Definition
observed and measurable by people other than the pt
Term
secondary source to get information include
Definition
family members
Term
two methods of collecting data is
Definition
the interview and physical exam
Term
actual nursing dx respresents
Definition
a condition that is currently present
Term
"risk for nursing dx" are those that
Definition
the pt is susceptible to but not yet trouble by
Term
a useful framework to guide prioritization is
Definition
maslows hierarchy of needs
Term
nursing orders identify
Definition
actions the nurse may begin independently
Term
nursing orders are necessary to provide
Definition
instruction for all caregivers
Term
implementation is the nurse
Definition
carrying out nursing orders to promote outcome achievement
Term
nursing orders must be
Definition
signed, dated and have specific designation to who will perform intervention and specifics about time of frequency of the intervention
Term
a variance exit is
Definition
when projected outcomes in not met
Term
the nurse organized data and those that are related are called
Definition
clusters
Term
focues assessments are performed
Definition
continously throughout nurse-pt contact based on the nursing care plan
Term
data clusters assist the nurse to
Definition
determine nursing diagnosis
Term
a head to toe format proveds a
Definition
systemic approach
Term
the nursing dx is the
Definition
basis for developing nursing interventions
Term
risk factors are those that increase
Definition
the susceptibilty of a pt to a problem
Term
the label of an actual nursing dx is
Definition
connected to the asessed cauesd by r/t
Term
a possible nursing dx requires
Definition
additional data to confirm a problem or complete a data cluster so that it can be related to a NANDA label
Term
during the planning phase
Definition
the nurse connects interventions to nursing orders
Term
plans are more effective when
Definition
the pt is involved in the process
Term
the nursing dx isnt evaluated what is
Definition
the pt progress toward the outcome is
Term
expected outcomes must be
Definition
pt-centered, measuable, and refer to a time fram
Term
when is an incident report filled out
Definition
when pt care was not cobsistent with faciltiy or national standards
Term
an incedent report explains what events
Definition
time, extent of jinjury and who was notified
Term
what is done when charging by exception
Definition
additional tx, changed in pts condition, and new concers during the shift
Term
institutions are reimnursed only for
Definition
pt care that is documented-nothing can protect a person from litigation
Term
critical pathways allow staff from all disciples to
Definition
develop integrated care plans for a projected length of stay for pts of specific case type
Term
home health care documentation has unique problems because
Definition
of the need of different health care workers to access the medical record
Term
OBRA was a significant Medicare and Medicaid legislation for
Definition
long-term health care documentation
Term
the nurse shouldnt read the medical record unless
Definition
there is a clinical reason to do so
Term
documentation is part of what phase of the nursind process
Definition
implementation phase
Term
logging off does what
Definition
closes the computer file that was opened with the nurses password
Term
ownership of the medical record belongs to
Definition
the institution in the case of a hospitalized pt, or teh doctor in the case of provate office visits
Term
POMR uses the acronym SOAPE in
Definition
format and focused charting on a list of pt problems/nursing dx
Term
QA is an in-house that
Definition
evaluates care services and results against accepted standards
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