Term
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Definition
Assessment
Diagnosis
Planning
Implementation
Evaluation |
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Term
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Definition
| Accurate data is collected |
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Term
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Definition
| Based on assessment, objective and subjective |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Response to implementation |
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Term
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Definition
| using scientific method to solve a problem |
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Term
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Definition
| develops from critical thinking |
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Term
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Definition
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Term
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Definition
| continuous quality improvement |
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Term
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Definition
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Term
| Skills for critical thinking |
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Definition
Effective reading
Effective writing
Effective communication
Concept mapping |
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Term
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Definition
| involves placing nursing diagnoses or nursing interventions in order of importance |
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Term
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Definition
| data obtained from the patient verbally |
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Term
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Definition
| Information obtained through the senses and hands on examination |
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Term
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Definition
Head
Vital signs
Heart and lung assessments
Abdomen
Extremities
Tubes and equipment
Pain status |
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Term
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Definition
| abnormalities that can be verified by repeat examination and are objective data |
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Term
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Definition
| factors the patient has said are occurring that cannot be verified by examination |
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Term
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Definition
| a broad idea of what is to be achieved through nursing intervention |
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Term
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Definition
| goals that are achievable within 7 to 10 days or before discharge |
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Term
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Definition
| often related to rehabilitation |
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Term
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Definition
| supposed to be initiated by an RN. In reality, LPN's often construct a plan for the approval of the RN. |
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Term
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Definition
| Once every 24 hours, the care plan is reviewed and updated |
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Term
| Independent nursing action |
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Definition
| does not require a physician's order |
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Term
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Definition
| requires a physician's order |
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Term
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Definition
| are those that come from collaboration care planning |
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Term
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Definition
| a step by step approach to the total care of the patient |
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Term
| Standard steps for all nursing procedures: Before procedures |
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Definition
Step A: Perform the task according to protocol
Step B: Check the order, collect the equipment and supplies, and perform hand hygiene
Step C: Identify and prepare patient
Step D: Provide privacy and institute safety precautions; arrange the supplies and equipment |
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Term
| Standard steps for all nursing procedures: During procedures |
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Definition
| Step E: Use standard precautions and aseptic technique as appropriate |
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Term
| Standard steps for all nursing procedures: After procedures |
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Definition
Step X: Remove gloves and other protective equipment
Step Y: Restore unit, collect the used equipment
Step Z: Record and report procedure |
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Term
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Definition
| is a legal record and can be used as evidence of events that occurred or treatment that was given |
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Term
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Definition
| Documentation, useful for evaluating staff, audited, adheres to accepted standards, improvement may be needed |
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Term
| Computerized provider order entry (CPOE) |
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Definition
| efficient work flow due to orders being automatically routed to computers in other clinical areas |
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