| A | B |
|---|
| analysis | a separate step in the nursing process or the 2nd phase of assessment. It incl.:1.the intellectual process of sorting & classifying data collected,2.recognizing patterns & discrepancies,comparing these w/ norms,3.id'ing pt responses to health prblms. that are amenable to nsg intervention |
| assessment | the organized, systematic, & continuous process of collecting data from a variety of sources. Data is collected abt the pts physical & psychosocial status.Data is obtained thru:1.interviews 2.observation 3.physical assess 4.review of the med.record(chart) &5.discussions w/ the fmly &/or sig.other |
| auscultation | refers to listening(usu.w/a stethoscope) to sounds produced by the body in order to differentiate normal from abnormal sounds. To perform this, you must 1st be able to recognize the normal variation in sounds. |
| biophysical factors | includes review of relevant major body systems |
| cues | subjective or objective pcs. of info obtained thru assess. |
| collaborative problems | certain physiologic complications that nurses monitor to detect their onset or changes in status |
| database | a series of pcs. of info about an individual & sig others that is used to ID strengths & unmet needs, & to establish a plan of care. It is also used for comparing the pt's status before & after the plan of care is implemented. |
| defining characteristics | clinical cues that cluster as manifestations of a nsg dx; categorized as major or minor |
| demographic information | such as age, address, & place of birth |
| diagnostic cues | clinical evidence that describes a cluster of behaviors or S & S that represents a diagnostic label. These are concrete & measurable thru observation or patient reports and are separated into major or minor. |
| discharge planning factors | such as where the person will go after di/c from a healthcare facility & with whom the person will live; knowledge of community resources; & accessibility of transportation, shopping, & health care facilities |
| educational needs | such as knowledge deficits revealed thru the interview process or by observation |
| environmental factors | incl. the persons' home living environment for such factors as the presence of running water, stairs & so forth, and the assistive devices req'd, such as walkers, canes, hearing aids, & glasses |
| evaluation | the process by which the outcomes of your nursing action are ID'd. The nurse is responsible to use this skill to determine that the care being provided to the patient through nursing care has been effective. This skill requires making a judgement call.eness of the nursing care |
| functional health pattern | describes the pt's strengths; also a model for organizing nursing diagnoses |
| high-risk nursing diagnosis | a clinical judgement that an individ., fmly., or community is more vulnerable to development of the problem than are others in the same or similar situation. This incl risk factors that guide nursing interventions to reduce or prevent the occurrence of the problem |
| implementation | putting the nursing care plan into action; the phase of the nursing process during which the actions planned are actually carried out. This nsg. skill incl:1.attitude toward pt 2.communication w/the pt 3.the tasks you carry out. This phase consists of providing nursing care, the "hands-on", "doing" segment of any procedure. It involves:1.admin.direct care 2.supervising the care provided by others, such as CNA's 3.teaching 4.counseling 5.ID'ing the need for referrals (i.e.home health) 6.carrying out orders of health care providers |
| independent interventions | nursing actions that are performed in collaboration with other members of the health care team |
| interventions (dependent) | nursing actions that are based on the MD's order |
| inference | assigning meaning to a cue or cluster of cues |
| inferencing | the process of assigning meaning to a cue or cluster of cues |
| inspection | the visual examination of a part or region of the body to assess normal conditions or deviations from normal. It is more than just looking. It is closely r/t observation, but is more involved w/physical than w/social info. Primarily, it is visual in nature; but also incl the sense of smell. This technique is deliberate, systematic, focused. It should incl observations of color, odor, size, shape, symmetry & movement (or lack of it). |
| medical history | includes previous hospitalizations, surgeries, and illness; medications taken; chronic health problems; and allergies |
| mental & emotional status | incl reactions to real/perceived stressors; general affect/mood; self-concept; body image; thought processes(ordered, disordered, or rational); interests & motivations; willingness to take risks; nonverbal communication (posture,hand motions,facial expressions);awareness of feelings and the manner of managing those feelings; & orientation to time, place & person |
| NANDA (The North Amercian Diagnostic Association) | an organization formed in the 1980's to promote the development of and education about nursing diagnoses. It has ID'd 3 types of nursing diagnoses; actual, high-risk & wellness diagnoses |
| nursing diagnosis | a clinical judgement about an individ, fmly, or community responses to actual or potential prblms/life processes. They provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable |
| nursing interventions | the specific actions that we will perform to help the patient achieve the desired outcomes |
| nursing process | a series of planned steps & actions directed at meeting the needs & solving the problems of the patients. It is a 5-step process: 1.Assessment 2. Diagnosis 3. Planning 4. Implementation & 5. Evaluation It is a continuous, on-going process, with no absolute beginning or end. The center of this is the patient and he/she is involved in each of the 5 steps. |
| objective data | "signs", information about the patient obtained by the nurse thru observations |
| outcomes | statements that describe the behavior the patient will display if the nsg. dx. is resolved. |
| patient profile | includes a description of the patient & a typical days' activities |
| palpation | the examination of the body thru the use of touch, & in most case is used simultaneously w/ inspection. Using the palms, fingers, & tips of the fingers, the nurse can ID softness, rigidity, masses & temp. & determine position & size. This will also be used to measure rate & quality of the peripheral pulses. |
| pediatric data base | may incl prenatal & OB hx, immunizations & observations about parent-child interactions, relationships w/ peers & developmental growth |
| percussion | an assessment technique involving the production of sound to obtain info about the underlying area; involvesstriking the body surface to produce sounds that enable an experienced examiner whether the underlying tissues are air-filled, fluid-filled, or solid. The examiner both hears (sounds change w/ the density of the tissue beneath) & feels the effects of this method. |
| performance evaluation | a set of measurable, observable statements used to determine how a student or graduate nurse compares with the expected standard |
| planning | the phase where you ID specific desired outcomes for the patient & determine the actions that will be needed to reach those outcomes. The plan of care includes 3 components:1.Nursing diagnosis 2.Outcomes 3.Interventions |
| planning - 2 | a process of setting prioritie, ID'ing achievable outcomes, developing strategies designed to support healthy responses, & prevent, minimize, or correct unhealthy responses ID'd in the nsg dx. |
| practice guidelines (protocols) | documents that specify nursing management of board clinical issues, phases of hospitalization, or interdependent clinical issues |
| quality improvement (Q.I.) | a systemic approach for improving the effectiveness of an organization while reducing costs |
| related factors | conditions/circumstances that can cause/contribute to the development of a dx. They can be environmental, physiological, psychosocial, or spiritual factors that contribute to the develpment of the problem. These must be changeable thru nsg interventions |
| risk-factors | ID'd behaviors, conditions, or cirucmstances that render an individ.,fmly, or community more vulnerable to a particular problem than others in the same/similar situation. There are no s & s (defining characteristics) for these because they represent potential, not actual, problems |
| self-care abilities | includes the ability to perform ADL's: feeding, bathing, dressing, grooming, toileting, & walking, and the ability to transfer from a bed to a wheelchair, toilet, or chair. |
| social & cultural history | includes a description of the patients' occupation, education, significant others, and spritual and social affiliations |
| substance abuse | such as use of mood-altering chemicals, such as street drugs & alcohol, abuse of prescription drugs & OTC drugs, & addiction to tobacco & caffeine |
| subjective data | "symptoms" -- are what INDIVIDUALS TELL YOU they are experiencing, feeling, seeing, hearing, or thinking |
| wellness diagnosis | defined as a clinical judgement about an individual, family, or community in transition from a specific level of wellness |
