Assessment
The systematic and continuous collection, analysis, validation, and communication of client data, o information.
What is "Assessing"?
A condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.
What is a "Health Problem"?
An expected conclusion to a client problem, or in the event of a wellness diagnosis, an expected conclusion to a client's health expectation.
What is a "Client outcome"?
After the data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings.
What is the "Evaluative statement"?
Two part statement includes a decision about how well the outcome was met, along with the client data or behaviors that support the decision.
Written or electronic legal record of all pertinent interactions with the client.
What is "Documentation"?
Includes all the pertinent client information collected by the nurse and other health care professionals. This information enables the nurse to partner with the client to develop a comprehensive and effective care plan.
What is a "Database"?
Actual or potential health problems that can be prevented or resolved by independent nursing intervention.
What is a "Nursing Diagnoses"?
Prepared plans of care that identify the nursing diagnosis, outcomes, and related nursing interventions common to a specific population or health problem
What is a "Standardized care plan"?
Levels of performance accepted by and expected of nursing staff or other health team members. They are established by authority, custom, or consent.
What are "standards"?
Protects the privacy of individually identifiable health information.
What is the Health Insurance Portability and Accountability Act (HIPAA)"?
Identifies the client's health status, strengths, health problems, health risks, and need for nursing care
What is the"Nursing history"?
Certain pathological complications that nurses monitor to detect onset or changes in status. The nurse monitors these situations with the physician prescribed and nursing interventions to minimize complications of the event.
What is "Collaborative Problems"?
Comprehensive standardized language used to describe the client outcomes that are responsive to nursing intervention.
What is "Nursing Outcome Classification (NOC)"?
Providing client care that evidence supports as likely to produce the expected outcomes.
What is "Evidence Based" nursing care?
The primary reason for the client record. It fosters continuity of care.
What is "Communication"?
Observable and measurable data that can be seen, heard felt, or measured by someone other than the person experiencing them.
What is "Objective Data"?
Grouping of the client data or cues that points to the existence of a health problem.
What is "Data Cluster"?
A treatment based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes. Interventions that nurses do on behalf of clients , both direct and indirect care.
What is "Nursing Interventions Classification (NIC)"?
Nurses committed to healthier clients, quality care, reduced costs, and the personal satisfaction of knowing they make a difference.
What is "Performance Improvement"?
4 steps: discover a problem, plan a strategy using indicators, implement change, and assess the change; if the outcome is not met , pan a new strategy.
Abbreviation for nothing by mouth.
What is "NPO"?
The nurse obtains the nursing history by talking to the client to obtain subjective data. This is a planned communication.
What is the "Interview"?
Problems that have been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.
What is an "Actual nursing diagnoses"?
The written guide that directs the efforts of the nursing team working with clients to meet their health goals.
What is the "Plan of Care (POC)"?
Special programs that promote excellence in nursing. They enable nursing to be accountable to society for the quality of nursing care.
What are "Quality Assurance programs"?
This model emphasis on quality cost effective care delivered within a limited time frame has led to the development of interdisciplinary documentation tools that clearly identify those outcomes that select groups of clients are expected to achieve on each day of care.
What is the "Case Management Model"?