Term
| Two sources of assessment gathering? |
|
Definition
Primary source: Patient
Secondary source: family members, medical records, change of shift reports, or other health care providers. |
|
|
Term
|
Definition
| establish a database about the client's perceived needs, health problems, and responses to these problems. |
|
|
Term
|
Definition
| Information obtained through your senses. |
|
|
Term
|
Definition
| your judgment or interpretation of cues that lead to a thought. Will direct you to further questions |
|
|
Term
| Problem oriented approach to assessment |
|
Definition
| focus on the client's presenting situations and begin with problematic areas for example back pain, difficulty breathing or apprehension over a procedure. |
|
|
Term
|
Definition
| describes human responses to health conditions or life processes that exist in an individual family or community. |
|
|
Term
|
Definition
| describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual family or community |
|
|
Term
| Health Promotion Nursing Diagnosis |
|
Definition
| clinical judgement of a person's family's or community's motivation and desire to increase well being and actualize human health potential as expressed in their readiness to enhanve specific health behaviors. |
|
|
Term
| Wellness nursing diagnosis |
|
Definition
| describes juman responses to levels of wellness in an individual family or community that have a readiness for enhancement...transition from a specific level of wellness to a higher level of wellness. "readiness for... related to" |
|
|
Term
| Definition of a diagnosis |
|
Definition
| client's response to health problem that the nurse can treat. |
|
|
Term
|
Definition
| preprinted document containing orders for the conduct of routine therapies, monitoring guidelines and or diagnostic procedures for specific clients with identified clinical problems. They direct the conduct of client care in carious clinical settings. |
|
|
Term
|
Definition
| a protocol that helps health care providers in making decisions about appropriate health care for specific clinical circumstances. |
|
|
Term
|
Definition
| Offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. |
|
|
Term
| 3 Implementation intervention skills |
|
Definition
| cognitive, interpersonal, psychomotor |
|
|
Term
| Activities of daily living |
|
Definition
| usually preformed during a day: eating, dressing, bathing, grooming, walking. |
|
|
Term
|
Definition
| activities allowing for independence in society, such as shopping, preparing meals, writing checks, and taking meds. |
|
|
Term
| Adverse Reactions/ Controlling for them |
|
Definition
| harmful or unintended effect of a med, diagnostic test, or therapeutic intervention. Our job is to counteract! IE ask for stimulant laxative when a patient is prescribed an opioid. ALWAYS REMEMBER TO EVALUATE FOR ADVERSE EFFECTS! |
|
|
Term
| The Evaluation Process: ICIDT |
|
Definition
| Identify evaluative criteria and standards. Collect data. Interpret and summarize findings. Document findings and clinical judgments. Terminate, continue, or revise the care plan. |
|
|
Term
| Quality Improvements/ Outcomes Management |
|
Definition
| Health care agencies are responsible for evaluating and improving the quality of client care services they provide. One method this can be achieved is through outcomes management. When nurses think in terms of outcomes management, their actions become more purposeful and focused on improving the condition of their client’s health. |
|
|
Term
|
Definition
| thoughts, communications, actions, customs, beliefs and institution of racial, ethnic, religious or social groups. |
|
|
Term
|
Definition
| represent various ethic, religious, and other groups with distinct characteristics from the dominant culture. |
|
|
Term
|
Definition
| : a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics. |
|
|
Term
|
Definition
| also known as multiculturalism, occurs when an individual identifies equally with two or more cultures. |
|
|
Term
|
Definition
| Health risks related to specific sociocultural and biological history. Some distinct health risks are due to the ecological context of the culture. What are people from different areas of the world more at risk for? Like immigrants from the Nile River who are generally at risk for parasitic infestations that are prevalent in that area, hypertension among african americans, etc. |
|
|
Term
| Theoretical approach to assessment |
|
Definition
| Using a structured database format based upon an accepted theoretical framework or practice standard. Examples include Gordon's 11 functional patterns which provides categories of information for assessment and offers a holistic framework for assessment of any health problem. |
|
|
Term
|
Definition
| name of nursing diagnosis in NANDA. Describes the essence of a client's response to health conditions in as few words as possible. |
|
|
Term
| Purpose of using a standard nursing diagnosis statement |
|
Definition
| Gives health care providers a common and recognizable language for understanding clients' needs. |
|
|
Term
| When needing assistance for a new procedure what 5 things should you do? |
|
Definition
| seek necessary knowledge (locate information info you need to be informed about the procedure, EBP), reassess the patient, collect all equipment, determine the consequences of the procedure, and have another nurse who has correctly completed the technique provide assistance and guidance. |
|
|
Term
|
Definition
| Identifying criteria and standards (knowing what to look for), collecting evaluative data, interpreting and summarizing findings, documenting findings, care plan revisions |
|
|
Term
| What is the intent of evaluation? |
|
Definition
| Determine if the known problems have remained the same, improved, worsened or otherwise changed. |
|
|
Term
| The Evaluative Process ICIDT |
|
Definition
1. Identify Evaluative Criteria and what needs to be evaluated (goals/ outcomes)
2. Collect evaluative data (assessment skills)
3. Interpret findings by comparing expected and actual findings.
4. Document results and clinical judgement and whether the client is progressing or not.
5. Terminate or revise care plan with new assessment and goals/ outcome. Modify unmet or partially met goals so they are more attainable. |
|
|
Term
|
Definition
| expected favorable and measurable results of nursing care. It defines the effectiveness, efficiency, and measurement of the results of nursing interventions. R/T factors no longer exist. |
|
|
Term
| Errors in data Clustering |
|
Definition
| occurs when you try to make the nursing diagnosis fit the signs and symptoms. |
|
|
Term
| Errors in Interpretation and Analysis of Data |
|
Definition
| When you are not able to validate data, signals an inaccurate match b/w clinical cues and the nursing diagnosis. Begin interpretation by identifying and organizing relevant assessment patterns to support the presences of client problems. |
|
|
Term
| Avoiding Errors in Diagnostic Statement |
|
Definition
| Use correct terminology reflecting client's response to the illness of condition. Uses standardized nursing language from NANDA. |
|
|
Term
| Avoiding errors in data collection |
|
Definition
| avoid inaccurate or missing data, and collect data in a organized way. |
|
|
Term
|
Definition
| broad statement that describes the desired change in a client's condition or behavior. In evaluation it is the expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state. |
|
|
Term
|
Definition
| measurable criteria to evaluate goal achievement, specific measurable change in a client's status that you expect to occur in response to nursing care. DETERMINE WHEN CLIENT CENTERED GOAL HAS BEEN MET. |
|
|
Term
| Requirements of goals and outcomes |
|
Definition
| client centered, relevant to client needs, specific, singular, observable, measurable, timeline, realistic, and a mutual idea between client and nurse. |
|
|
Term
|
Definition
| specific and measurable behavior response that reflects a client's highest possible level of wellness and independence in function. It is realistic and based on client needs and resources. CONTAINS ONLY ONE BEHAVIOR OR RESPONSE! |
|
|
Term
|
Definition
| multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition. IT ENSURES BETTER CONTINUITY OF CARE BECAUSE IT MAPS OUT CLEARLY THE RESPONSIBILITY OF EACH HEALTH CARE DISCIPLINE. it maps out day to day/hour to hour the recommended interventions and expected outcomes for a client. |
|
|
Term
|
Definition
| involve the safe and competent administration of nursing procedures. Must be knowledgeable about the procedure to carry it out. |
|
|
