Term
| a set of actions leading to a particular goal |
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Definition
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Term
| an organized sequence of problem solving steps used to identify & manage health problems of clients |
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Definition
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| serves as a roadmap that guides staff involved in clients care |
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Definition
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Term
| Characteristics of nursing process |
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Definition
| within legal scope of practice, based on knowledge & requires critical thinking, plan systematic steps, goal directed, prioritized, dynamic |
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Term
| What are the steps to the nursing process |
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Definition
A-assessment
D-diagnosis
P-planning
I-implementation
E-evaluation |
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Term
| The first step of the nursing process which is a systematic collection of facts |
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Definition
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Definition
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| symptoms-only what the client can feel or describe |
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Definition
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Term
| what is the primary source of data |
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Definition
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Term
| who is the secondary source of data |
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Definition
| anyone other than the client |
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Term
| initial info about the clients physical, emotional, social, spiritual health "baseline" |
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Definition
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| info that provides more details about specific client problems, expands the initial assessment |
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Definition
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Term
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Definition
grouping related info
assessment findings
related clusters |
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Term
| second step of the nursing process, identification of health related problems, results from analyzing collected data & determining normal & abnormal findings |
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Definition
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Term
| a health issue that can be prevented, reduced, resolved, or enhanced through independant nursing measures |
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Definition
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Term
| where do nursing diagnosis come from |
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Definition
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Term
| what are some nursing diagnostic statements |
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Definition
problem ex pain
etiology ex related to knee surgery
sxs ex pt stated level 10 pain |
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Term
| doctors & nurses must work together for ______ _______ |
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Definition
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Term
| Actual diagnosis describes a ______problem |
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Definition
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Term
| in an actual diagnosis how many of the 3 parts of the diagnostic statement must be met |
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Definition
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Term
| _______ ________is potential problem, only meets 2 parts of the diagnostic statement & is missing which part______ |
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Definition
risk diagnosis
sxs missing |
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Term
| the dr diagnosis which contains treatments, medical conditions, r/t anatomy, physiology, disease & trauma |
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Definition
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Term
| unlike medical dx, nursing dx are patient_____ |
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Definition
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Term
| what is the third step of the nursing process |
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Definition
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Term
| in this step priorities are set & the problems are ranked using Maslows Hierachy, idenitify goals & outcomes, select interventions, document plan of care |
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Definition
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Term
| short term goals are achievable in_____ |
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Definition
| within a few days to a week |
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Term
| long term goals should be met in |
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Term
| what is the 4th step, carrying out the plan |
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Definition
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Term
| a method of organizing info in a graphic or pictoral form |
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