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| Use of critical thinking skills to obtain relevant information about the Pt and plan and provide effective care, and measure outcomes. Used throughout the nursing process. |
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| Visual representation of client problems and interventions that shows their relationships to each other. Metacognitive tool that assists learners in developing a self-appraisal of their own individual thinking processes and in considering the context of nursing practice in the conceptualization of client problems. |
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| Active, organized, cognitive process used to carefully examine one's thinking and the thinking of others. |
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| Process that enables an observer to assign meaning and to classify phenomena in clinical situations by integrating observations and critical thinking. |
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| evidenced-based knowledge |
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| Knowledge that comes from scientific investigation or knowledge that is based on clinical expertise |
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| Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. |
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| A prediction of the probable outcome of a disease or condition of a client and the usual course of the disease as observed in similar situations |
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| First step of the nursing process. Activities required in the first step are data collection, data validation, data sorting, and data documentation; the purpose is to gather information for health problem identification. |
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| Data collected about a client's present level of wellness, changes in the client's life patterns, sociocultural role, and mental and emotional reactions to an illness. |
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| Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. |
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| Data relating to a client's health problem that are obtained through observation or diagnostic measurements. |
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| Measure or guide that serves as a basis for comparison when evaluating similar phenomena or substances. |
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| Data relating to a client's health problem that are given in the client's own words. |
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| Nursing direction response to a problem ; provides the basis for selection of nursing interventions for which the nurse is accountable. |
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| What nursing leaders and educators revised their curricula to reflect. |
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| Cluster of signs and symptoms that are observed in the client and that imply a specific nursing diagnosis. |
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| The name of a nursing diagnosis as approved NANDA International |
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| Identification of the cause of a problem. The cause may be a direct or a contributing factor in the development of a client problem or need. |
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| Identification of a specific disease or pathological process. |
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| North American Nursing Diagnosis Association |
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| A condition or etiology identified from the client's assessment data |
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| Human response to health conditions/live processes that may develop in a vulnerable individual, family, or community. |
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| A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. |
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| collaborative intervention |
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| Therapies that require the combined knowledge, skill and expertise of multiple health care professionals. |
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| Tool used in managed care that incorporates the treatment interventions of caregivers from all disciplines who normally care for a client. Designed for a specific case type, a pathway is used to manage the care of a client throughout a projected length of stay. |
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| dependent nursing intervention |
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| Those actions that require an order from a physician or another health care professional |
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| Likely condition of a client at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education. |
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| independent nursing intervention |
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| Actions that a nurse initiates without direction from a physician or other health care professional. |
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| Trade name for card-filing system that allows for quick reference to the particular need of the client for certain aspects of nursing care. |
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| Objective that is expected to be achieved over a longer period of time, usually over weeks or months. |
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| Written guidelines of nursing care that document specific nursing diagnoses for the client and goals, interventions, and projected outcomes. |
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| The order of nursing diagnoses using notations of urgency and/or importance, in order to establish a preferential order for nursing actions |
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| A document that guides decisions and interventions for specific health care problems or conditions |
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| Treatments preformed through interaction with the client. |
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| Treatments performed away from the client but on behalf of the client or group of clients. |
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| The fourth step of the nursing process, the nurse initiates the interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status. |
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| interdisciplinary care plan |
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| Plans that represent the contributions of all disciplines caring for the client. |
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| Any action by a nurse that implements the nursing care plan or any specific objective of the plan. |
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| Written and approved document containing rules, policies, procedures, regulations, and orders for the conduct of client care in various stipulated clinical settings. |
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| Condition to be achieved as a result of health care delivery. Favorable or adverse changes in clients' health states due to prior or concurrent care. |
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| A term that encompasses managing the individual clinical outcomes of clients as a result of prescribed treatments to the formal measurement of system level performance and effectiveness. |
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| Term interchangable with quality improvement that describes and approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others. |
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| Monitoring and evaluation of processes and outcomes in health care or any other business to identify opportunities for improvement. |
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| Minimum level of care accepted to ensure high quality of care to clients. Standards of care define the types of therapies typically administered to clients with defined problems or needs. |
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| lumbar vertebrae, one to five |
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| Licensed vocational nurse |
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