Term
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Definition
| Collecting data about the client usuing physical assessment and interviewing techniques |
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Term
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Definition
| Using client data and critical thinking skills to identify and validate an appropriate nursing diagnosis |
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Term
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Definition
| Writing measurable client outcomes and interventions to accomplish outcomes |
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Term
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Definition
| Initiating the care plan and performing the planned interventions |
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Term
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Definition
| Determining if outcome(s) met and appropriateness of the interventions to meet client needs |
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Term
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Definition
| General survey of patient that provides a quick situational assessment of urgent/non-urgent problems; situations needing immediate action; safety, environmental, or equipment concerns; does the patient seem to be "alright?" |
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Term
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Definition
| The patient is visually systematically examined for appearance, structure, function, and behavior |
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Term
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Definition
| Examination of different organs of the body using the hands and fingers (sense of touch) |
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Term
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Definition
| The location, size, and density of an organ are assessed using the sound produced by short, sharp taps |
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Term
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Definition
| Listening with a stethoscope to the sounds produced within different body structures created by the movement of air and fluid |
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Term
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Definition
| 36-38C (96.8-100.4F); oral-98.6F avg |
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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
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Term
| Normal Blood Pressure range |
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Definition
<120/<80
acceptable range: 90-140/60-90 |
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Term
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Definition
| An organized dynamic process involving three basic activities: (a) systematically gathering data, (b) sorting and organizing the collected data, and (c) documenting the data in a retrievable fashion |
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Term
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Definition
| Formal statement of an actual or potential health problem that nurses can legally and independantly treat; the analysis of collected data to identify the client's needs or problems, draw conclusions regarding specific needs or human responses of concern; formal statement of an actual or potential health problem that nurses can legally and independantly treat |
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Term
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Definition
| Process of designing interventions to achieve the goals and outcomes of health care delivery; client needs are prioritized, goals are established, desired outcomes are determined to measure the client's progress toward achieving the goals |
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Term
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Definition
| Initiation and completion of the nursing actions necessary to help the patient achieve health care goals; plan of care is put into action; interventions must be consistent with establishes plan of care |
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Term
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Definition
| Determination of the extent to which established patient goals have been achieved; an ongoing process; a constant measuring and monitoring of the client's status to determine (a) appropriateness of nsg actions, (b) need to revise interventions, (c) development of new client needs, (d) need for referral to other sources, (e) need to rearrange priorities to meet demands of care |
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