NURS 204- Unit 2, Lesson 5

etiology

the cause, set of causes, or manner of causation of a disease or condition

judgement

the ability to make considered decisions or come to sensible conclusions

diagnostic

concerned with the diagnosis (nature, identification) of illness or other problems

relevant

closely connected or appropriate to what is being done or considered

inference

a conclusion reached on the basis of evidence and reasoning

esteem

respect and admiration, typically for a person

allocate

distribute (resources or duties) for a particular purpose; assign, issue, award

formulate

create or devise methodically (strategy or a proposal); express an idea in a concise or systemic way

essence

the intrinsic nature or indispensable quality of something, especially something abstract, that determines its character

denote

be a sign of; indicate

attain

succeed in achieving (something that one desires and has worked for)

heirarchy

an arrangement or classification of thing according to relative importance or inclusiveness; people and groups can be ranked according to status or authority

criteria

a principle or standard by which something may be judged or decided

manifestation

an event, action, or object that clearly shows or embodies something; a symptom or sign of an ailment

systemic

relating to a system, especially as opposed to a particular part

delegate

a person sent or authorized to represent others; entrust (a task or responsibility) to another person

actualize

make a reality of

analyze

examine methodically and in detail the constitution or structure of something, typically for purposes of explanation and interpretation

nursing process

a cyclical, critical thinking process that consists of 5 steps to follow in a purposeful, goal-directed, systematic way to achieve optimal client outcomes

• primary means of directing the sequence, planning, implementation, and evaluation of nursing care to achieve specific health goals

ADPIE

acronym of the nursing process

• assessment

• diagnosis

• planning

• implementation

• evaluation

Assessment

collect data/information about the client’s health status

diagnosis

analyze the data to determine the client’s health status or problem

planning

set priorities, determine client outcomes, and select specific nursing interventions

implementation

perform nursing actions, delegate tasks, supervise other health care staff and document the care and client’s responses

evaluation

evaluate (rate) the client’s responses to nursing interventions and determine the effectiveness of the nursing care plan

subjective data (stated)

-what the patient tells the nurse

-cannot prove; subject to interpretation

objective (observed)

-data the nurses obtain through observation/examination and other sources

-observations include the utilization of all senses

-can prove; measurable and descriptive data

• weight, blood pressure, pain level, lung sounds, appearance, etc.

Gordon’s Functional Health Pattern Assessment Framework

a holistic model of a person-environment interaction that helps nurses systematically organize assessment data obtained through history taking (collecting subjective data) and physical examination (gathering objective data)

data analysis

converting raw data into meaningful information

Clustering information

Making an inference

Nursing diagnosis (ND)

NANDA

Problem focused diagnosis

risk diagnosis

health promotion diagnosis

syndrome

Three part format

two part format

Consider urgency

assess interactions

respect patient preferences

apply Maslow’s hierarchy of needs

Initial planning

a comprehensive plan of care based on a comprehensive assessment on admission

ongoing

-throughout the provision of care

-while new information and evaluating responses to care, they modify and individualize the initial plan of care

discharge

-a process of anticipating and planning for client’s needs after discharge

-to be effective, discharge planning must be done during admission

outcome identification

nurses work with clients to identify goals and outcomes

• concise and measurable

Subject

Who is expected to achieve the outcome?

• patient, family, community, all?

Verb

• What is the behavior the patient should do?

• what action must the subject take to achieve the outcome?

Performance Criteria

• it must be measurable

• how well is the subject to perform the action?

Condition

• Under what condition is it done?

• under what circumstances is the subject to perform the action?

Target time

• What is the time frame to do it?

• By when is the the subject expected to perform the action?

Planning care

nurses identify actions and interventions that help achieve optimal outcomes

Autonomous intervention

nurse initiated- when the nurse uses evidence and scientific rationale to take autonomous actions to benefit the client

interdisciplinary intervention

provider initiated- the nurse initiates as a result of a provider’s prescription or the facility protocol

interdisciplinary intervention

Collaborative interventions- those the nurse carries out in collaboration with other health care team professionals

individual’s status

evaluate clients’ responses to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes

individual’s progress toward goal achievement

continuously evaluate clients’ progress toward outcomes and use clients’ data to determine whether to modify the plan of care

care plan’s status and currency

determine the effectiveness of the nursing care plan

• collect data based o the outcome criteria then compare to what actually happened with the planned outcomes

taxonomy

a hierarchal method of classifying vocabulary terms according to certain rules

• provides a way to classify and categorize areas of concern to nursing professional

standardized language

a structured, uniform vocabulary used to document nursing diagnoses, interventions, and outcomes in electronic health records