CH 5 – Nursing Process & Critical Thinking

ACTUAL NURSING DIAGNOSIS
Human responses to health conditions / life processes that exist in an individual, family, or community. It is supported by defining characteristics that cluster in patterns or related cues or inferences.

ASSESSMENT
A systemic, dynamic process by which the nurse, through interaction with the client, significant others, & health care providers, collects & analyzes data about the client.

BIOGRAPHIC DATA
Relating to the facts and events of a person’s life.

CASE MANAGEMENT
(Now a certified nursing specialty) Refers to the assignment of a health care provider to a pt so that the care of that pt is overseen by one individual.

CLINICAL PATHWAY
A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, high-cost cases. (Synonyms: critical paths, multdisciplinary action plans, action plans, care maps.)

COLLABORATIVE PROBLEM
Certain physiologic complications that nurses monitor to detect onset or changes in status. Use of physician-prescribed & nursing-prescribed interventions. EX: Potential Complication: hypoglycemia.

CUE
Synonym for subjective & objective data.

DATABASE
A large store or bank of information. (From which the nursing diagnosis can be identified).

DEFINING CHARACTERISTICS
Cues that tell how the diagnosis is manifested — The clinical cues, signs, & symptoms that furnish evidence that the problem exists.

DIAGNOSE
To identify the type & cause of a health condition. (ANA def. – a clinical judgment about the client’s response to actual or potential health conditions or needs, The diagnosis provides the basis for determination of a plan of care to achieve expected outcomes.)

EVALUATION
A determination made about the extent to which the established outcomes have been achieved. — Review pt-centered goals, Reassess pt to gather data about pts actual response to nursing interventions, Compare the actual outcome with desired outcome, Make critical judgment as to whether outcome was achieved.

GOAL (STATEMENT)
A statement about the purpose to which an effort is directed.

IMPLEMENTATION
Established plan is put into action to promote outcome achievement. — 5th phase of nursing process — Includes: ongoing activities of data collection, prioritization, performance of nursing interventions, & documentation.

MANAGED CARE
A health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame.

MEDICAL DIAGNOSIS
The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test, & procedures.

NANDA
North American Nursing Diagnosis Association – approved official definitions of a nursing diagnosis that are still in current use.

NURSING DIAGNOSIS
Clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. — Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

NURSING INTERVENTION
Those activities that should promote the achievement of the desired pt outcome — May include activities that the nurse selects to resolve a nursing diagnosis, to monitor for the development of a risk problem, or to carry out physician orders.

NURSING PROCESS
Serves as the organizational framework for the practice of nursing. — A systematic method by which nurses plan & provide care for pts. — Consists of 6 dynamic & interrelated phases: assessment, diagnosis, outcome identification, planning, implementation, & evaluation.

NURSING-SENSITIVE OUTCOMES
The results or outcomes of nursing interventions. These outcomes or indicators are influenced by nursing & can be used to judge effectiveness of care & determine best practices.

OBJECTIVE DATA (SIGNS)
Observable & measurable data that can be recorded. EX: rash, lesions, puffy eyes, crying, slurred speech, temperature elevation.

OUTCOME (Desired Pt Outcome)
States the behaviors that the pt will be able to perform rather than the nurse will do. — 2 functions: 1.) Guide the selection of interventions — 2.) Establishes the measuring standard that is used to evaluate the effectiveness of the nursing interventions.

PLANNING
Nurse establishes priorities of care, selects & converts nursing interventions into nursing orders, and communicates the plan of care using standardized languages or recognized terminology to document the plan.

PROBLEM
Any health care condition that requires diagnostic, therapeutic, or educational action. —

RISK NURSING DIAGNOSIS
Human responses to health conditions / life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that are present that are known to contribute to the development of a problem.

STANDARDIZED LANGUAGE
A structured vocabulary that provides nurses with a common means of communication.

SUBJECTIVE DATA (SYMPTOMS)
Verbal statements provided by the pt. EX: nausea, fatigue, anxiety.

SYNDROME NURSING DIAGNOSIS
Used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances. CURRENT: Post-trauma, Rape-trauma, Risk for disuse, Impaired environmental interpretation, Relocation stress.

VARIANCE
When a pt does not achieve the projected outcome. — Exit — Are examined by members of the interdisciplinary team to determine whether the failure to achieve the outcome was a system, provider, or pt problem. — Analysis is used to promote continuous quality improvement.

WELLNESS NURSING DIAGNOSIS
Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

NURSING
The protection, promotion, and optimization of health & abilities, prevention of illness and injury, alleviation of suffering through the diagnosis & treatment of human response, & advocacy in the care of individuals, families, communities, & populations.

FOCUS ASSESSMENT
Is advisable when a pt is critically ill, disoriented, or unable to respond — Gathers info about a specific health problem —

PRIMARY SOURCES OF DATA
The patient.

SECONDARY SOURCES OF DATA
Include family members, significant others, medical records, diagnostic procedures, nursing literature, & other health care team members.

2 BASIC METHODS OF COLLECTING DATA
Pt Interview. & physical examination.

PT INTERVIEW DATA
Health history, biographic data, information about the reason the pt is seeking health care, history of present illness, family history, environmental history, psychosocial history, followed by review of systems.

DATA CLUSTERING
Occurs when related cues are grouped together, attention being focused on health concerns. (Also assists in identification of the nursing diagnosis).

GUIDELINES FOR SIGNIFICANT CUES
1.) Deviations from population norms — 2.) Any change in the pts usual health status — 3.) Developmental delays — 4.) Dysfunctional behavior — 5.) Changes in usual behavior

NURSING DIAGNOSIS COMPONENTS
1.) Nursing diagnosis title/label — 2.) definition of the title/label — 3.) Contributing /etiologic /related factors — 4.) defining characteristics.

RISK FACTORS
Those circumstances that increase the susceptibility of a pt to a problem.

4 TYPES OF NURSING DIAGNOSIS
1.) Actual nursing diagnosis — 2.) Risk — 3.) Syndrome — 4.) Wellness

PT OUTCOME STATEMENT
Provides a description of the specific, measurable behavior (outcome criteria) that the pt will be able to exhibit in a given time frame following the interventions.

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