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Nursing Process Terms
assess (nursing process step) - Determine the need for nursing care. concept mapping - An instructional strategy that requires learners to identify, graphically display, and link key concepts. Concept maps, also called cognitive maps, mind maps, and meta cognitive tools for learning, are a proven means to promote critical thinking and self-directed learning. critical thinking - A systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned. critical thinking indicators - Evidence based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. decision making - Purposeful, goal directed effort applied in a systematic way to make a choice among alternatives. [Lipe and Beasley (2004)] evaluate - Reassess the patient for effectiveness of care. expected outcomes - Specific, measurable criteria used to evaluate whether the patient goal has been met. implement - Putting into motion the plan of care. intuitive problem solving - A direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. nursing diagnosis - Actual and potential health problems. nursing process - A systematic method that directs the nurse and patient, as together they accomplish the following: Assessment, Diagnosis, Outcome Identification/Planning, Implementation, and Evaluation. care plan -
A detailed schedule outlining the practitioner's and the patient's activities and responsibilities designed to achieve goals of therapy, and to resolve and prevent drug therapy problems. scientific problem solving - A systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. standards for critical thinking - Attributes include: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair. trial-and-error problem solving - Involves testing any number of solutions until one is found that works for that particular problem. assessing - The systematic and continuous collection, validation, analysis, and communication of patient data, or information. cue - A hint or clue that something may be wrong. data - Information. database - Includes all the pertinent patient information collected by the nurse and other healthcare professionals. emergency assessment - Identifies life threatening problems. focused assessment - The nurse gathers data about a specific problem that has already been identified. inference - The judgment you reach about a cue. initial assessment - Performed shortly after the patient is admitted to a healthcare agency or service. interview - A planned communication. minimum data set - Specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster this data.
data cluster - A grouping of patient data or cues that points to the existence of a patient health problem. diagnosing - Purpose includes: (1) identify how an individual, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. diagnostic error - Erroneously labeling selected patient health patterns as unhealthy. health problem - A condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness. medical diagnoses - Identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. nursing diagnoses - Actual or potential health problems that can be prevented or resolved by independent nursing intervention. possible nursing diagnoses - Statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem. risk nursing diagnoses - Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. standard - A generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category; a norm. syndrome nursing diagnoses - Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post- Trauma Syndrome. wellness diagnoses - Clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. clinical pathways -
Tools used in case management to communicate the standardized, interdisciplinary plan of care for patients. critical pathways - Same as a clinical pathway. CareMaps - Another name for clinical or critical pathways. computerized plans of nursing care - A nursing care plan that is part of an electronic medical record consultation - A process in which two or more individuals with varying degrees of experience and expertise discuss a problem and it's solution. criteria - Measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. They describe acceptable levels of performance by stating the expected behaviors of the nurse or the patient. discharge planning - Best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources. expected outcome - Used to refer to the more specific measurable criteria used to evaluate the extent to which a goal has been met. goal - An aim or an end. initial planning - Developed by the nurse who performs the admission nursing history and the physical assessment. A comprehensive plan that addresses each problem listed in the prioritized nursing diagnoses and identifies approriate patient goals and the related nursing care. Kardex care plan - The plan of nursing care for each patient is concisely recorded on a folded card and placed in a central file where it is easily accessible. nursing intervention - Any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes. nursing interventions classifications (NIC) -
nurse-initiated intervention - Independent nursing actions or nurse-prescribed interventions carried out as in response to patient needs identified during assessment and noted in the plan of care, as well as any other actions that nurses initiate without direction or supervision of another healthcare professional. nursing interventions - Defined by the Nursing Interventions Classification (NIC) project as "any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes". physician-initiated intervention - Dependent nursing actions that involve carrying out physician-prescribed orders. protocols - Written plans that detail the nursing activities to be executed in specific situations. standing orders - Empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. unlicensed assistive personnel (UAP) - Individuals who are trained to function in an assistive role to the licensed registered nurse (RN) in the provision of patient activities as delegated by and under the supervision of the registered professional nurse. concurrent evaluation - Conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met. criteria - Measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. They describe acceptable levels of performance by stating the expected behaviors of the nurse or the patient. evaluating - The nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care. nursing audit - A method of evaluating nursing care that involves reviewing patient records to assess the outcomes of nursing care or the process by which these outcomes were achieved. outcome evaluation - Evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care. peer review -
The evaluation of one staff member by another staff member on the same level in the hierarchy of the organization; an important mechanism nurses can use to improve their professional performance. performance improvement - Commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met. process evaluation - Evaluation that focuses on the nature and sequence of activities carried out by nurses implementing the nursing process. quality-assurance program - Specialty designed program that promotes excellence in nursing. quality improvement - The commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes. retrospective evaluation - Evaluation that may use post discharge questionnaires, patient interviews, or chart review to collect data. standards - The levels of performance accepted and expected by the nursing staff or other health team members. They are established by authority, custom, or consent. structure evaluation - Focuses on the environment in which care is provided. change-of-shift report - Given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient. charting by exception (CBE) - Shorthand documentation method that makes use of well defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. collaborative pathway - Same as critical pathway; used in the case management model; specifies the plan of care linked to expected outcomes along a timeline. confer - Consult with someone to exchange ideas or to seek information, advice, or instructions. consultation -
Outcome and Assessment Information Set - key component in Medicare's partnership with the home care industry to foster and monitor improved home healthcare outcomes. patient record - A compilation of a patient's health information. personal health record (PHR) - Records that contain an individual's medical history, including diagnoses, symptoms, and medications. PIE charting - Unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes in which problems are identified by number. problem-oriented medical record (POMR) - Originated in the 1960s by Dr. Lawrence Weed; organized around a patient's problems rather than around sources of information. progress notes - Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes. referral - The process of sending or guiding the patient to another source for assistance. SBAR communication - (Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition. SOAP format - (Subjective, Objective, Assessment, Plan) - used to organize data entries in the progress notes of the POMR. source-oriented record - Documentation system in which each healthcare group records data on its own separate form. variance charting - The usual format is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate.
