Process- Ch. 16, 17, 18, 19, 20, 21 (Assessment,
Diagnosis, Planning, Implementation, Evaluation,
Managing Patient Care)- Q&A
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Terms in this set (80)
identification of a disease condition based on a
specific evaluation of physical S/S, PT's medical
medical diagnosis
history, and the results of diagnostic tests and
procedures, cannot be treated by nurses
clinical judgment made by a nurse to describe a
patient's response or vulnerability to health conditions
nursing diagnosis or life events that a nurse is licensed and competent
to treat, diagnostic label that classifies an individual's,
family's, or community's response to illness
problem that requires both medicine and nursing
collaborative problems
interventions to treat, examples: seizures, bleeding
provides standard, formal diagnostic statements
NANDA-I (definitions, defining characteristics, and related/risk
factors)
a comprehensive, research-based, standardized
Nursing Intervention
classification of multidisciplinary interventions and
Classification (NIC)
associated activities
, system of organizing desired patient outcomes
according to categories, classes, labels, outcome
Nursing Outcome indicators, and measurement activities for outcomes.
Classification (NOC) links outcomes to NANDA-I nursing diagnoses,
standardized way of determining if nursing
interventions are successfulnur
standard terminology system for nursing diagnoses
International Classification used around the world, includes 7 axes with
for Nursing Practice definitions (focus, judgment, client, action, means,
(ICNP) location, and time). diagnoses are categorized as
positive or negative with associated outcomes
type of diagnosis when there is an increased potential
or vulnerability for a patient to develop a problem or
risk diagnosis complication. statement has two parts: diagnostic
label and associated risk factors preceded by the
phrase "as evidenced by"
type of diagnosis when there is an identified
undesirable human response to existing problems or
problem-focused
concerns of a patient. statement has three parts:
diagnosis
diagnostic label, related factors, and major defining
characteristics
type of diagnosis where there is an identified desire or
motivation to improve health status through a positive
health promotion
behavioral change. statements have two parts:
diagnosis
diagnostic label and defining
characteristics/assessment findings
group of data elements, the signs or symptoms
data clusters
gathered during assessment
objective or subjective signs, symptoms, or risk factors
data elements that leads you into making a diagnostic conclusion,
offer cues to a type of health problem
component of a nursing diagnosis that names the
diagnostic label nursing diagnosis (approved by NANDA-I, ICNP, or
another system)