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foundation of nursing 1 terms > Nursing Process > Flashcards

Nursing Process Flashcards

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1
Q

blended competencies

A

set of intellectual, interpersonal, technical, and ethical/legal capacities needed for professional nursing

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2
Q

clinical judgment

A

result of critical thinking or clinical reasoning

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3
Q

clinical reasoning

A

referring to ways of thinking about patient care issues, reasoning about clinical issues

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4
Q

creative thinking

A

involves imagination, intuition, and spontaneity

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5
Q

critical thinking

A

thoughts that are disciplined, comprehensive, and based on intellectual standards

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6
Q

decision making

A

goal-directed effort applied in a systematic way to make a choice

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7
Q

intuitive problem solving

A

direct understanding of a situation based on a background of experience, knowledge, and skill

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8
Q

nursing process

A

5 step method of giving patient care

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9
Q

person-centered care

A

Based on holistic roots, every clinical encounter is used to assess how the person is doing

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10
Q

Quality and safety education for nurses (QSEN)

A

Prepares future nurses with the knowledge, skills, and attitudes (KSA) necessary to improve the healthcare system

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11
Q

reflective practice

A

caregiver has a profound awareness of self and own biases, understand how they may affect the therapeutic relationship

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12
Q

scientific problem solving (7 steps)

A

Problem identification, data collection, hypothesis formulation, plan of action, hypothesis testing, interpretation of results, evaluation

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13
Q

thoughtful practice

A

care of a patient by a caregiver who uses clinical reasoning and reflective practice to guide thoughtful actions and person-centered care

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14
Q

trial and error problem solving

A

involves testing any number of solution until one is found that works for that problem

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15
Q

assessing

A

systematically and continuously collect, validate and communicate patient data

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16
Q

cue

A

significant information that is helpful for decision making

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17
Q

database

A

all pertinent patient info that enables a effective plan of care

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18
Q

focused assessment

A

assess specific problem or highest priority concerns

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19
Q

inference

A

judgment reached about a cue

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20
Q

initial assessment

A

comprehensive assessment, baseline data to make judgments about health status, need for nursing and to plain individualized care

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21
Q

interview

A

planned communication for a specific purpose

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22
Q

minimum data set

A

specifies the info that must be collected from every patient

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23
Q

nursing history

A

identify patient’s health status, strengths, health problems, health risks, and need for nursing care

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24
Q

objective data

A

perceptible to the sense, verified by another person

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25
Q

observation

A

conscious and deliberate use of the five senses to gather data

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26
Q

patient-centered assessment method (PCAM)

A

assesses patient complexity using the social determinants of health

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27
Q

physical assessment

A

objective, better defines patient’s condition and helps plan care

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28
Q

Review of systems (ROS)

A

physical examination of all body systems

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29
Q

subjective data

A

info perceived only by the affected person

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30
Q

collaborative problem

A

health problem that may occur from complications of disease or treatment. nurse works with other members of the health care team

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31
Q

data cluster

A

grouping of patient data or cues that point to the existence of a health problem

32
Q

diagnosing

A

analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve

33
Q

diagnostic error

A

failure to detect an actual unhealth behavior or condition

34
Q

health problem

A

condition related to health requiring intervention if disease or illness is to be prevented or resolved

35
Q

health promotion nursing diagnosis

A

behavior of an individual motivated by a personal desire to increase well-being and health potential

36
Q

medical diagnosis

A

statement about a specific disease process using terminology from a well-developed classification system

37
Q

nursing diagnosis

A

actual or potential health problem that an independent nursing intervention can prevent or resolve, characteristics are present as risk factors

38
Q

risk nursing diagnosis

A

clinical judgments that an individual or community is more vulnerable to develop the problem than others in the same situation

39
Q

syndrome

A

cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation

40
Q

clinical or critical pathways (CareMaps)

A

Case management tools used to communicate the standardized plan of care for a particular group of patients

41
Q

collaborative interventions

A

interdependent nursing actions performed jointly by nurses and other members

42
Q

computerized plans of nursing care

A

plans of patient care developed by computers that enable nurses to use plans for diagnoses

43
Q

criteria

A

specified behavior, measurable criteria

44
Q

discharge planning

A

preparing the patient to leave the healthcare facility

45
Q

initial planning

A

addresses each problem in the nursing diagnoses and identifies patient goals

46
Q

nurse initiated intervention

A

independent nursing actions that involve carrying out nurse prescribed interventions or interventions based on patient needs

47
Q

nursing intervention

A

any treatment based on clinical judgment and knowledge, performed to enhance patient outcomes

48
Q

Nursing interventions classification (NIC)

A

list of nursing interventions applicable to all settings that can be used by nurses

49
Q

Nursing outcomes classification (NOC)

A

presents comprehensive standardized language used to describe patient outcomes that relate to intervention

50
Q

ongoing planning

A

carried out by any nurse who interacts with the patient, keeps plan up to date, manage risk factors

51
Q

outcome identifcation

A

patient demonstrating resolution of the problems identified, has a time frame

52
Q

patient outcome

A

expected conclusion to health problem

53
Q

physician-initiated intervention

A

dependent nursing actions, carrying out physician prescribed orders

54
Q

planning

A

establish patient goals to prevent, reduce, or resolve, the problems identified in the nursing diagnoses and determination of related nursing interventions

55
Q

standardized care plans

A

prepared plan of care for a specific population or problem

56
Q

clinical inquiry

A

ongoing process of questioning and evaluating practice and advancing informed practice

57
Q

delegation

A

transfer of responsibility, still have accountability for the outcome

58
Q

direct care intervention

A

treatment performed through interaction with the patient

59
Q

evidence-based practice

A

nursing care provided that is supported by scientific rationale

60
Q

implementing

A

carry out the plan of care

61
Q

indirect care interventions

A

treatment performed away from the patient but on behalf of the patient

62
Q

protocols

A

written plan that details the nursing activities to be executed in certain situations

63
Q

standing orders

A

document that details the nursing care to be implemented in specific nursing situations

64
Q

unlicensed assistive personnel (UAP)

A

trained to function in an assistive role to the RN, is delegated

65
Q

concurrent evaluation

A

evaluation of nursing care and patient outcomes while the patient is receiving care

66
Q

evaluating

A

measurement of the extent to which the patient has achieved the goals specified in the plan of care, identify negative and positive factors that influence goals

67
Q

evaluative statement

A

judgment summarizing the nurse’s findings after data has been collected and interpreted

68
Q

National database of nursing quality indicators (NDNQI)

A

Database of nursing sensitive quality indicators aimed at promoting and facilitating the standardization of info

69
Q

nursing sensitive quality indicators

A

identify structures of care and care processes that influence care outcome

70
Q

outcome evaluation

A

focuses on measurable changes in the health status of the patient or end results of nursing care

71
Q

performance improvement

A

commitment to healthier patients, making a difference, reduce costs, planning a strategy, implementing a change, and assessing the change to see if the goal is met

72
Q

process evaluation

A

focusing on the nature and sequence of activities carried out by nurses implementing the nursing process

73
Q

quality assurance program

A

ongoing evaluation of excellence of health care, may assess structure, process, and outcome standards

74
Q

quality improvement (QI)

A

commitment and approach used to improve every process in every part of an organization. means to met and exceed expectations and outcomes

75
Q

retrospective evaluation

A

evaluation of nursing care and patient outcomes after patient has been discharged

76
Q

standards

A

rules that allow nurses to carry out professional roles

77
Q

structure evaluation

A

focuses on the environment in which care is provided, an audit

foundation of nursing 1 terms (16 decks)

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