| A | B |
|---|
| Nursing Diagnosis | Provides the basis for determination of a plan of care to achieve expected outcomes; three part statement, words "related to" links the first and second parts of the statement. "As evidenced by (AEB)” joins the second and third parts of the diagnostic statement. |
| Nursing Care Plans | Written guidelines for client care; organized so nurse can quickly identify nursing actions to be delivered. |
| Biographic Data | Provides info about the facts or events in a person's life |
| Diagnose | Identify the type and cause of a health condition; clinical judgment about the client's response to actual or potential health conditions or needs |
| Evaluation | The nurse appraises the patient's progress toward attainment of outcomes |
| Four Components of Nursing Diagnosis | 1. Nursing diagnosis title/label. 2. Definition of the title/label. 3. Contributing/etiologic/related factors and 4. Defining characteristics |
| Goal | Statement about the purpose to which an effort is directed. Example. The nurse might want to prevent constipation or promote activity |
| Implementation | Established/identified plan is put into action/executed to promote outcome achievement includes ongoing activities of data collection, prioritization, performance of nursing interventions and documentation |
| Managed Care | A health care system that involves administrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated and costs are reduced. Health education and preventive medicine are emphasized |
| Medical Diagnosis | Identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test and procedures; physicians make these diagnoses. Ex. Congestive heart failure |
| NANDA | North American Nursing Diagnosis Association |
| Nurse Process Phases | Assessment, Diagnosis, Planning, Implementation and Evaluation |
| Nurse-Prescribed Interventions | Any actions that a nurse can legally order or begin independently |
| Nursing Interventions | These activities should promote the achievement of the desired patient outcome |
| Nursing Process | Systematic method by which nurses plan and provide care for patients. Serves as the organizational framework for the practice of nursing. |
| Objective Data | Observable and measurable signs |
| Outcome Identification | The RN identifies expected results for a plan individualized to the patient or situation. States the behaviors that the patient will be able to perform rather than what the nurse will do. Measurable verbs such as describe, list, walk, demonstrate and verbalize should be used. |
| Physician-Prescribed Interventions | Those actions ordered by a physician for a nurse or other health care professional to perform |
| Planning | The RN develops a blueprint that prescribes priorities of care, strategies and alternatives to attain expected outcomes |
| Problem | Any health care condition that requires diagnostic, therapeutic or education action |
| Risk Nursing Diagnosis | Human responses to health conditions/life processes that may develop in a vulnerable individual, family or community; two part statement connected by words "related to" example; _ _ _ _ for impaired skin integrity related to mechanical or shearing forces. |
| Subjective Data | Verbal statements provided by the patient |
| Critical Thinking | Process through which nurses analyze and make sense of situations in order to make sound clinical decisions. |
| Linear | Critical thinking and nursing judgment is NOT a _ _ _ _ _ _ step by step process. |
| Initial Comprehensive Assessment | Nurses perform this when they first admit a client to a hospital setting, when they accept a new client into a physician's office or clinic, and when they first visit a home healthcare client. |
| Observation & Interviews | Two methods nurses use to make an initial assessment. |
| Focused Assessment | Nurses complete this on clients whose problem has been identified to note whether that problem has worsened, improved, or resolved. |
| Ongoing Assessment | Nurses complete this assimilation of gathered data continuously and throughout all the phases of the nursing process. |
| Emergency Assessment | Completed for life-threatening situations when nurses must remember their ABCs—airway, breathing, and circulation, especially for clients with heart or lung problems. |
| NANDA Categories | Health Promotion, Nutrition, Elimination, Activity/Rest |
| Maslow’s Hierarchy of Needs | A useful method for setting priorities that consists of five interdependent levels of basic human needs that must be satisfied in a sequence starting with the lowest level. |
| Assessment | Systemic, dynamic, comprehensive process by which the nurse through interaction with the client analyzes data pertinent to the patient's health or the situation. |
