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Ch.5 key terms


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Angelique Galvan


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A systematic, dynamic way collect and analyze data about a client the first step in delivering nursing care

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A systematic, dynamic way collect and analyze data about a client the first step in delivering nursing care
Biographic data
Provide info about the facts or events in a person’s life
Case management
Encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for patient.
Clinical pathway
A multidisciplinary plan that incorporates EBP guidelines for high-risk, high-volume, high-cost types of cases while providing the optimal patient outcome and maximizing clinical efficiency
Collaborative problems
Health-related problems that the nurse anticipates based on condition or diagnosis of patient
Cue
A piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur
Database
A large store or bank of info(for the patient)
Defining characteristics
The clinical cues, signs, and symptom's that furnish evidence that the problem exists
Diagnose
To identify the type the type and cause of health condition
Evaluation
A determination made about the extent to which the established goals have been achieved
Goal
The purpose to which an effort is directed
Implementation
Phase of the nursing process, the nurse and other members of the team put the established plan into action to promote goal achievement (fifth phase of nursing process)
Managed care
Refers to healthcare systems that have control over primary health care services and attempt to trim down health care costs by reducing unnecessary or overlapping services
Medical diagnosis
Identification of a disease or condition with the evaluation of physical signs, sympr toms, patient interviews, laboratory tests, diagnostic procedures, review of medical records, and patient hise tory
NANDA-I
To reflect nursing diagnosis terminology used atound the world.
Nursing diagnosis/patient problem statement
Is a type of health problem that can be identified by the nurse
Nursing interventions
Are those activities that promote the achievement of the desired patient goal
Nursing process
A systematic method by which nurses plan and provide care for patients
Nursing-sensitive patient outcomes
Identification of outcomes that are responsive to nursing care is important work for nursing, especially in connection with efforts to , contain costs and establish best practices
Objective data
Are observable and measurable signs
Outcome(goal)
These classification systems, further provide research-based information regarding nursing treatments and judgments
Planning
Phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the patient problem statement.
Potential patient problem statement
Are written as two part statements: (1) the patient problem statement withthe adjective"potential" in front of it, and (2) the risk factor(s).
Standardize language
Terms that have the same definition and meaning regardless of who uses them
Subjective data
Are information that is provided by the patient
Variance
Unexpected event that occurs during the use of a clinical pathway (can be positive or negative)