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A collection of information used to develop a plan of care
Admission Database
and discharge goals with the patient's input.
The use of the best research-based evidence combined
Evidence-Based Practice (EBP) with clinician expertise and consideration of patient pref-
erences.
A problem-solving tool used to identify and manage pa-
Nursing Process
tients' health care needs.
The phase where the nurse gathers information about the
Assessment Phase
patient to diagnose patient strengths and problems.
The phase that determines whether the desired patient
Evaluation Phase outcomes have been met and whether the nursing inter-
ventions were appropriate.
The measurable results that indicate the effectiveness of
Patient Outcomes
nursing interventions.
Actions taken by nurses to improve patient health out-
Nursing Interventions
comes.
A condition characterized by a deficiency of blood volume,
Hypovolemia
often due to excessive fluid loss.
The nurse's ability to make decisions based on patient
Clinical Judgment
data, experience, and evidence.
The services provided to patients to maintain or improve
Patient Care
their health.
A framework that guides nursing practice and helps to
Nursing Theory
understand patient care.
The process of evaluating data to determine the effective-
Data Analysis
ness of patient care.
The individual choices and values of patients that should
Patient Preferences
be considered in their care.
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An approach that considers biological, psychological, and
Biopsychosocial Nature
social factors in patient care.
Positive attributes and resources that patients possess to
Patient Strengths
aid in their recovery.
Conditions that negatively affect a patient's physical or
Health Problems
mental well-being.
The amount of fluids consumed by a patient, which is
Fluid Intake
crucial for maintaining hydration.
The process of teaching patients about their health con-
Patient Education
ditions and care plans.
Plans made for the care of children while a parent is
Child Care Arrangements
hospitalized or otherwise occupied.
The state of physical and emotional well-being of a patient
Patient Comfort
during care.
The specialized knowledge and skills that a clinician has
Clinical Expertise
acquired through experience.
A detailed outline of the nursing interventions and patient
Nursing Care Plan
goals for care.
The systematic collection of patient data to inform care
Patient Assessment
decisions.
A comprehensive document that contains a patient's med-
Health Record
ical history and care details.
The prevention of errors and adverse effects associated
Patient Safety
with patient care.
Working together with other healthcare professionals to
Collaboration in Nursing
provide optimal patient care.
Patient-Centered Care
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An approach that respects and responds to individual
patient preferences, needs, and values.
An infection caused by bacteria, which can lead to various
Bacterial Infection
health complications.
Diaphoresis Excessive sweating, often associated with fever or illness.
Clinical Problem Statement Includes problem, causes, signs, and symptoms.
Nursing Diagnosis Subjective and objective data supporting patient issues.
Assistive Personnel (AP) Can measure vital signs like blood pressure.
Scope of Practice Defines tasks appropriate for each nursing role.
Licensed Practical Nurse (LPN) Can perform specific tasks like glucose measurement.
Case Manager Role Coordinates patient care across multiple settings.
For patients needing rehabilitation before home dis-
Transitional Care Facility
charge.
Home Health Aide Assists with personal hygiene and daily living activities.
Quality Care Initiatives Focus on improving patient outcomes and satisfaction.
Delegation Assigning tasks to appropriate healthcare team members.
Patient Goals Expected outcomes set to guide nursing interventions.
Assessment Initial evaluation of patient's health status.
Interventions Planned actions to achieve patient care goals.
Influences quality care based on outcomes and satisfac-
Health Care Financing
tion.
Reimbursement Policies Determine hospital payments based on care quality.
Patient Monitoring Ongoing assessment of patient's health status.
Vital Signs Key indicators of patient health, like pulse and BP.
Nursing Responsibilities