Chapter 9 Nursing Process
assessment -
the first step of the nursing process. The activities required in the first step are data
collection, data validation, data sorting, and data documentation. The purpose is to gather
information for health problem identification.
back-channeling -
An active listening technique that prompts a respondent to continue telling a story
or describing a situation.This iInvolves use of phrases such as "Go on," "Uh huh," and "Tell
me more."
clinical practice guideline -
a systematically developed set of statements that helps nurses and other HCPs
make decisions about appropriate health care for specific clinical situations
close-ended question -
question that limits the patient's answers to one or two words, and is used to
clarify previous information or provide additional information
collaborative interventions -
therapies that require the knowledge, skill, and expertise of multiple health care
professionals
concept map -
visual representation of patient problems and interventions that shows their
relationships to each other. Metacognitive tool that assists learners in developing a self-
appraisal of their own individual thinking processes and in considering the context of nursing
practice in the conceptualization of patient problems
consultation -
process in which the help of a specialist is sought to identify ways to handle
problems in patient management or in the planning and implementing of programs
counseling -
problem-solving method that is used to help patients recognize and manage stress
and to enhance interpersonal relationships. It helps patients examine alternatives and decide
which choices are most helpful and appropriate
critical pathway -
multidisciplinary, outcome based care plan
cue -
information that a nurse acquires through hearing, visual observations, touch, and
smell
data analysis -
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, logical examination of and professional judgment about patient assessment data,
which is used in the diagnostic process to derive a nursing diagnosis
data cluster -
set of signs or symptoms that are grouped together in logical order
database -
information about a patient's level of health, health practices, past illnesses,
present illnesses, and physical examination combined to serve as the basis for the plan of care
defining characteristics -
related signs and symptoms or clusters of data that support the nursing diagnosis
dependent nursing interventions -
nursing actions that require an order from a physician or another health care
professional
direct care interventions -
treatments performed through interaction with the patient. For example, a patient
may require medication administration, insertion of an intravenous infusion, or counseling
during a time of grief
etiology -
study of all factors that may be involved in the development of a disease
evaluation -
determination of the extent to which established patient goals have been achieved
expected outcome -
expected conditions of a patient at the end of therapy or of a disease process,
including the degree of wellness and the need for continuing care, medications, support,
counseling, or education
functional health patterns -
method for organizing assessment data based on the level of patient function in
specific areas, for example, mobility
goal -
desired results of nursing actions, set realistically by the nurse and patient as part
of the planning stage of the nursing process
health history -
information about a patient's physical and developmental status, emotional health,
socal practices and resources, goals, values, lifestyle, and expectations about the health care
system
implementation -
initiation and completion of the nursing actions necessary to help the patient
achieve health care goals
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assessment -
the first step of the nursing process. The activities required in the first step are data
collection, data validation, data sorting, and data documentation. The purpose is to gather
information for health problem identification.
back-channeling -
An active listening technique that prompts a respondent to continue telling a story
or describing a situation.This iInvolves use of phrases such as "Go on," "Uh huh," and "Tell
me more."
clinical practice guideline -
a systematically developed set of statements that helps nurses and other HCPs
make decisions about appropriate health care for specific clinical situations
close-ended question -
question that limits the patient's answers to one or two words, and is used to
clarify previous information or provide additional information
collaborative interventions -
therapies that require the knowledge, skill, and expertise of multiple health care
professionals
concept map -
visual representation of patient problems and interventions that shows their
relationships to each other. Metacognitive tool that assists learners in developing a self-
appraisal of their own individual thinking processes and in considering the context of nursing
practice in the conceptualization of patient problems
consultation -
process in which the help of a specialist is sought to identify ways to handle
problems in patient management or in the planning and implementing of programs
counseling -
problem-solving method that is used to help patients recognize and manage stress
and to enhance interpersonal relationships. It helps patients examine alternatives and decide
which choices are most helpful and appropriate
critical pathway -
multidisciplinary, outcome based care plan
cue -
information that a nurse acquires through hearing, visual observations, touch, and
smell
data analysis -
1|Page
, logical examination of and professional judgment about patient assessment data,
which is used in the diagnostic process to derive a nursing diagnosis
data cluster -
set of signs or symptoms that are grouped together in logical order
database -
information about a patient's level of health, health practices, past illnesses,
present illnesses, and physical examination combined to serve as the basis for the plan of care
defining characteristics -
related signs and symptoms or clusters of data that support the nursing diagnosis
dependent nursing interventions -
nursing actions that require an order from a physician or another health care
professional
direct care interventions -
treatments performed through interaction with the patient. For example, a patient
may require medication administration, insertion of an intravenous infusion, or counseling
during a time of grief
etiology -
study of all factors that may be involved in the development of a disease
evaluation -
determination of the extent to which established patient goals have been achieved
expected outcome -
expected conditions of a patient at the end of therapy or of a disease process,
including the degree of wellness and the need for continuing care, medications, support,
counseling, or education
functional health patterns -
method for organizing assessment data based on the level of patient function in
specific areas, for example, mobility
goal -
desired results of nursing actions, set realistically by the nurse and patient as part
of the planning stage of the nursing process
health history -
information about a patient's physical and developmental status, emotional health,
socal practices and resources, goals, values, lifestyle, and expectations about the health care
system
implementation -
initiation and completion of the nursing actions necessary to help the patient
achieve health care goals
2|Page
