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Flashcards

Adult Health - Potter & Perry Chapter 16-20 Vocabulary

hannah martin English 71 cards

Cards in this deck (71)

  1. 1nursing processcritical thinking five-step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
    assess, diagnose, plan, implement, evaluate
  2. 2assessmentthe deliberate and systematic collection of information about a patient to determine the patients current and past health and functional status and his or hers present and past coping patterns
  3. 3nursing assessment steps1. collection of information from primary source (patient) and secondary sources (family, friends, professionals, medical record)
    2. the interpretation and validation of data to ensure a complete database
  4. 4cueinformation that you obtain through the use of senses
  5. 5inferenceyour judgment or interpretation of these cues
  6. 6functional health patterstheory or practice standard provides categories of information for you to assess
  7. 7health perception-health management patterndescribes patients self-report of health and well being, how patient manages health (frequency of healthcare provider visits, adhere to therapies), knowledge of preventative health practices
  8. 8nutritional metabolic patterndescribes patients daily and weekly pattern of food and fluid intake (restrictions, special diet, appetite), actual weight, weight loss or gain
  9. 9elimination patternpatterns of excretory function (bowel, bladder, and skin)
  10. 10activity exercise patternpatterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
  11. 11sleep rest patternpatterns of sleep, rest and relaxation
  12. 12cognitive perceptual patternsensory perceptual patterns, language adequacy, memory, and decision making ability
  13. 13self-perception and self- concept patternpatients self concept pattern and perceptions to self (self worth, emotional patterns, body image)
  14. 14role relationship patternpatients patterns of role engagements and relationships
  15. 15sexuality reproductive patternpatterns of satisfaction and dissatisfaction with sexuality pattern, reproductive patterns, pre and postmenopausal problems
  16. 16coping stress tolerance patternability to manage stress, previous coping responses, sources of support, effectiveness of coping on stress
  17. 17value belief patternvalues, beliefs, and goals that guide patient choices and decisions
  18. 18subjective datapatients verbal descriptions of there health problems
  19. 19nature of pain"describe your pain"
  20. 20precipitating factors"Do you notice if pain worsens during any activity or specific time of day?"
  21. 21severity"rate the pain on a scale 0 to 10"
  22. 22objective dataobservations or measurements of a patients health status
  23. 23open ended questionsprompts patient to describe a situation in more than a few words
  24. 24back channelingactive listening prompts to indicate that you are listening and interested in hearing more details
  25. 25closed ended questionslimits the answer to yes or no
  26. 26nursing health historykey component of a comprehensive assessment
  27. 27areas of health historyphysical, developmental, intellectual, spiritual, social, and emotional
  28. 28OPQRSTonset, provocation, quality, radiation, severity, time
  29. 29concomitant symptomssymptoms accompanying the primary symptom
  30. 30review of systemsa systematic approach for collecting subjective information from patients about the presence or absence of health-elated issues each body system
  31. 31validationcomparison of data with another source to determine the datas accuracy
  32. 32medical diagnosisidentification of a disease condition based on a specific evaluation of physical signs and symptoms, patients medical history, and the results of diagnostic tests and procedures
  33. 33nursing diagnosisclinical judgement concerning a human response to health conditions/ life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat
  34. 34collaborative problemactual or potential physiological complication that nurses monitor to detect the onset of changes in a patients health status
  35. 35American Nursing Diagnosis Association International (NANDA-I)several hundred diagnosis listed and research teams
  36. 36problem-focused nursing diagnosisclinical judgement concerning an undesirable human response to a health condition. life process that exists in an individual, family, or community
  37. 37defining characteristicsobservable assessment cues such as physical signs or patient behavior, that support each problem-focused diagnostic judgement
  38. 38related factoretiological or causative factor for the diagnosis
  39. 39risk nursing diagnosisclinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions
  40. 40health promotion nursing diagnosisclinical judgement concerning a patients motivation and desire to increase well-being and actualize human health potential
  41. 41diagnostic labelname of the nursing diagnosis as approved by NANDA
  42. 42planningnurse collaboration with the patient, family, and healthcare team to determine the urgency of identified problems and prioritize patient needs
  43. 43priority settingordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
  44. 44priority setting stepsassessment, problem identification, problem prioritizing, identify desired outcomes, identify interventions to achieve outcomes, prioritize interventions, deliver patient care, evaluate interventions
  45. 45goalbroad statement that describes a desired change in a patients condition, perceptions, or behavior
  46. 46expected outcomemeasurable change that must be achieved to reach a goal
  47. 47patient-centered goalreflects a patients highest possible level of wellness and independence in function
  48. 48nursing-sensitive patient outcomemeasurable patient, family, behavior, or perception largely influenced by and sensitive to nursing interventions
  49. 49components of goals and expected outcomesspecific, singular, measurable, attainable, realistic, and timed
  50. 50independent nursing interventionsnurse initiated without supervision or direction from others
  51. 51dependent nursing interventionshealthcare provider initiated interventions
  52. 52nursing care planincludes nursing diagnoses, goals, expected outcomes, nursing interventions, and evaluation findings to identify a patients clinical needs and situation
  53. 53scientific rationalereason for choosing specific nursing action based on supporting evidence
  54. 54writing nursing interventionsprecise, indicate frequency, indicate quantity, indicate method
  55. 55implementationformally begins after you develop a plan of care
  56. 56nursing interventionany treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes
  57. 57direct caretreatment interventions through interaction with the patient
  58. 58indirect caretreatments performed away from a patient but on behalf of the patient (safety, infection control, documentation, collaboration)
  59. 59clinical practice guidelinessystematically developed set of statements that helps nurses and healthcare professionals make decisions about appropriate health care for specific clinical situations
  60. 60standing orderpreprinted document containing orders for routine therapies, monitoring guidelines, or diagnostic procedures for specific patients with identified clinical problems
  61. 61preparing for implementationtime management, equipment, personnel, environment, patient
  62. 62implementation skillscognitive, interpersonal, psychomotor
  63. 63activities of daily living (ADLs)activities usually performed in a normal day; ambulation, eating, dressing, bathing, and grooming
  64. 64instrumental activities of daily living (IADLs)skills such as shopping, meal prep, housecleaning, check writing, taking medication
  65. 65lifesaving measurephysical care technique that you use when a patients physiological or psychological state is threatened
  66. 66counselingdirect care method that helps patients use problem solving processes to recognize and manage stress and facilitate interpersonal relationships
  67. 67adverse reactionharmful or unintended effect of a medication, diagnostic test, or therapeutic intervention
  68. 68preventative nursing actionspromote health and prevent illness to avoid the need for acute or rehabilitative health care
  69. 69interdisciplinary care planscontributions of all disciples caring for the patient
  70. 70patient adhereancepatients and families invest time carrying out required treatments
  71. 71evaluative measuresexamine the results of care by observation, physiological measurements, measurement scales, or patient interview

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Flashcards on Adult Health - Potter & Perry Chapter 16-20 Vocabulary, created by hannah martin on 06/09/2018.
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hannah martin
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