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Nursing Process
A systematic approach to patient care that includes assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
Assessment
The first step in the nursing process where information is gathered to establish a client database.
Mental Status Examination (MSE)
A structured assessment that evaluates the patient's cognitive, emotional, and psychological functioning.
Psychosocial Assessment
An evaluation of a patient's social, emotional, cultural, and spiritual factors affecting their mental health.
Outcomes Identification
The step where specific, measurable outcomes reflecting the highest level of patient health are defined.
Nursing Outcomes Classification (NOC)
A standardized classification of patient outcomes developed to evaluate the effect of nursing interventions.
Planning
The phase in the nursing process that involves developing strategies to accomplish the identified outcomes.
Nursing Interventions Classification (NIC)
A standardized language that describes treatments that nurses perform in all settings.
Implementation
The execution of the interventions established during the planning phase.
Evaluation
The process of measuring progress toward the attainment of expected outcomes.
Legal and ethical guidelines
Regulations and moral principles that dictate appropriate behavior in nursing practice.
Autonomy
The principle of respecting the rights of individuals to make their own decisions.
Beneficence
The duty to promote good and act in the best interests of the patient.
Nonmaleficence
The principle of doing no harm to the patient.
Justice
The ethical principle that emphasizes fairness and equality in the distribution of resources.
Fidelity
Maintaining loyalty and commitment; doing no wrong to a patient.
Veracity
The duty to always communicate truthfully to the patient.
Informed Consent
A legal process where a patient gives permission for treatment based on an understanding of the risks and benefits.
Confidentiality
The ethical principle of keeping patient information private and secure.
HIPAA
The Health Insurance Portability and Accountability Act that protects patient privacy and confidential health information.
Client Rights
Legal entitlements that patients have regarding their treatment and information.
Voluntary Admission
When a patient seeks treatment for themselves or gives consent for treatment.
Involuntary Commitment
When a patient is admitted for treatment without their consent, often due to safety concerns.
Emergency Commitment
Temporary admission of a person for observation and treatment when they are in crisis.
Malpractice
A legal concept referring to professional negligence that results in harm to the patient.
Negligence
The failure to take proper care in providing a service, leading to damage or injury.
Breach of Confidentiality
When private patient information is disclosed without consent.
Assault and Battery
Legal terms for threatening harm to another person and the actual act of causing harm.
Documentation
The process of recording patient care and responses to treatment, vital for legal and ethical standards.
Mental Health Laws
Legal regulations guiding the care and treatment of individuals with mental health disorders.
Bioethics
Ethics focused on dilemmas arising from advances in biology and medicine.
Values Clarification
A process that helps individuals identify and rank their personal values.
Patient's rights
Legal entitlements that ensure patients receive fair treatment and services in healthcare.
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