Flashcards
Adult Health - Potter & Perry Chapter 16-20 Vocabulary
Flashcards do conjunto (71)
- 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 - 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
- 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 - 4cueinformation that you obtain through the use of senses
- 5inferenceyour judgment or interpretation of these cues
- 6functional health patterstheory or practice standard provides categories of information for you to assess
- 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
- 8nutritional metabolic patterndescribes patients daily and weekly pattern of food and fluid intake (restrictions, special diet, appetite), actual weight, weight loss or gain
- 9elimination patternpatterns of excretory function (bowel, bladder, and skin)
- 10activity exercise patternpatterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
- 11sleep rest patternpatterns of sleep, rest and relaxation
- 12cognitive perceptual patternsensory perceptual patterns, language adequacy, memory, and decision making ability
- 13self-perception and self- concept patternpatients self concept pattern and perceptions to self (self worth, emotional patterns, body image)
- 14role relationship patternpatients patterns of role engagements and relationships
- 15sexuality reproductive patternpatterns of satisfaction and dissatisfaction with sexuality pattern, reproductive patterns, pre and postmenopausal problems
- 16coping stress tolerance patternability to manage stress, previous coping responses, sources of support, effectiveness of coping on stress
- 17value belief patternvalues, beliefs, and goals that guide patient choices and decisions
- 18subjective datapatients verbal descriptions of there health problems
- 19nature of pain"describe your pain"
- 20precipitating factors"Do you notice if pain worsens during any activity or specific time of day?"
- 21severity"rate the pain on a scale 0 to 10"
- 22objective dataobservations or measurements of a patients health status
- 23open ended questionsprompts patient to describe a situation in more than a few words
- 24back channelingactive listening prompts to indicate that you are listening and interested in hearing more details
- 25closed ended questionslimits the answer to yes or no
- 26nursing health historykey component of a comprehensive assessment
- 27areas of health historyphysical, developmental, intellectual, spiritual, social, and emotional
- 28OPQRSTonset, provocation, quality, radiation, severity, time
- 29concomitant symptomssymptoms accompanying the primary symptom
- 30review of systemsa systematic approach for collecting subjective information from patients about the presence or absence of health-elated issues each body system
- 31validationcomparison of data with another source to determine the datas accuracy
- 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
- 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
- 34collaborative problemactual or potential physiological complication that nurses monitor to detect the onset of changes in a patients health status
- 35American Nursing Diagnosis Association International (NANDA-I)several hundred diagnosis listed and research teams
- 36problem-focused nursing diagnosisclinical judgement concerning an undesirable human response to a health condition. life process that exists in an individual, family, or community
- 37defining characteristicsobservable assessment cues such as physical signs or patient behavior, that support each problem-focused diagnostic judgement
- 38related factoretiological or causative factor for the diagnosis
- 39risk nursing diagnosisclinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions
- 40health promotion nursing diagnosisclinical judgement concerning a patients motivation and desire to increase well-being and actualize human health potential
- 41diagnostic labelname of the nursing diagnosis as approved by NANDA
- 42planningnurse collaboration with the patient, family, and healthcare team to determine the urgency of identified problems and prioritize patient needs
- 43priority settingordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
- 44priority setting stepsassessment, problem identification, problem prioritizing, identify desired outcomes, identify interventions to achieve outcomes, prioritize interventions, deliver patient care, evaluate interventions
- 45goalbroad statement that describes a desired change in a patients condition, perceptions, or behavior
- 46expected outcomemeasurable change that must be achieved to reach a goal
- 47patient-centered goalreflects a patients highest possible level of wellness and independence in function
- 48nursing-sensitive patient outcomemeasurable patient, family, behavior, or perception largely influenced by and sensitive to nursing interventions
- 49components of goals and expected outcomesspecific, singular, measurable, attainable, realistic, and timed
- 50independent nursing interventionsnurse initiated without supervision or direction from others
- 51dependent nursing interventionshealthcare provider initiated interventions
- 52nursing care planincludes nursing diagnoses, goals, expected outcomes, nursing interventions, and evaluation findings to identify a patients clinical needs and situation
- 53scientific rationalereason for choosing specific nursing action based on supporting evidence
- 54writing nursing interventionsprecise, indicate frequency, indicate quantity, indicate method
- 55implementationformally begins after you develop a plan of care
- 56nursing interventionany treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes
- 57direct caretreatment interventions through interaction with the patient
- 58indirect caretreatments performed away from a patient but on behalf of the patient (safety, infection control, documentation, collaboration)
- 59clinical practice guidelinessystematically developed set of statements that helps nurses and healthcare professionals make decisions about appropriate health care for specific clinical situations
- 60standing orderpreprinted document containing orders for routine therapies, monitoring guidelines, or diagnostic procedures for specific patients with identified clinical problems
- 61preparing for implementationtime management, equipment, personnel, environment, patient
- 62implementation skillscognitive, interpersonal, psychomotor
- 63activities of daily living (ADLs)activities usually performed in a normal day; ambulation, eating, dressing, bathing, and grooming
- 64instrumental activities of daily living (IADLs)skills such as shopping, meal prep, housecleaning, check writing, taking medication
- 65lifesaving measurephysical care technique that you use when a patients physiological or psychological state is threatened
- 66counselingdirect care method that helps patients use problem solving processes to recognize and manage stress and facilitate interpersonal relationships
- 67adverse reactionharmful or unintended effect of a medication, diagnostic test, or therapeutic intervention
- 68preventative nursing actionspromote health and prevent illness to avoid the need for acute or rehabilitative health care
- 69interdisciplinary care planscontributions of all disciples caring for the patient
- 70patient adhereancepatients and families invest time carrying out required treatments
- 71evaluative measuresexamine the results of care by observation, physiological measurements, measurement scales, or patient interview
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- FlashCards sobre Adult Health - Potter & Perry Chapter 16-20 Vocabulary, criado por hannah martin em 06-09-2018.
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