Fill in the boxes with the correct definitions for the words found in your reading for this week. Once complete, turn the forms into Engrade in the appropriate turn-it-in slot. Vocabulary words are due the day before class, by midnight. Please use this form and fill out electronically.
Word / DefinitionChapter 10
Assess / To systematically and continuously collect, validate and communicate patient data
Concept mapping / Instructional strategy that requires learners to identify, graphically display and link key concepts
Critical thinking / A process involving imagination, intuition and spontaneity-factors that underpin the art of nursing
Critical thinking indicators / Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice
Decision making / Purposeful, goal-oriented effort applied in a systematic way to make a choice among alternatives
Evaluate / Measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised
Expected outcomes / Specific, measurable criteria used to evaluate whether the patient goal has been met
Implement / Carry out the plan of care
Intuitive problem solving / Direct understanding of a situation based on a background of experience, knowledge, and skills that makes expert decision making possible
Nursing process / Actual or potential health problem that an independent nursing intervention can prevent or resolve. Actual problem is present. Possible problem may be present, but more data are needed to confirm or disconfirm the problem. Potential problem may occur; defining characteristics are present as risk factors
Plan / Establish patient goals to prevent, reduce or resolve the problems identified in the nursing diagnoses and determination of related nursing interventions
Scientific problem solving / Systematic problem-solving process that involves 1) problem identification, 2) data collection, 3) hypothesis formulation, 4) plan of action, 5) hypothesis testing, 6) interpretation of results, and 7) evaluation resulting in conclusion or revision of the study
Standards for critical thinking / Clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose) and fair
Trial-and-error problem solving / Method of problem solving that involves testing any number of solutions until one is found that works for that particular problem
Chapter 11
Assessing / Systematic and continuous collection, analysis, validation and communication of patient data
Cue / Significant information that is helpful in making decisions
Data / Information
Database / All the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented
Emergency assessment / Rapid focused assessment conducted to determine potentially fatal situations
Focused assessment / Assessment conducted to assess a specific problem; focuses on pertinent history and body regions
Inference / The judgement reached about a cue
Initial assessment / Comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgement about a patient’s health status
Interview / Planned communication for a specific purpose
Minimum data set / A standard established by health care institutions that specifies the information that must be collected from every patient
Nursing history / Assessment of the patient by interview to identify the patient’s health status, strengths, health problems, health risks and need for nursing care
Objective data / Information perceptible to the senses; may be verified by another person
Observation / Conscious and deliberate use of the five senses to gather data
Physical assessment / Systematic examination of the patient for objective data to better define the patient’s condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient’s body systems
Review of systems (ROS) / Physical examination of all body systems in a systematic manner as part of the nursing assessment
Subjective data / Information perceived only by the affected person
Time-lapsed assessment / An assessment that is scheduled to compare a patient’s current status to base-line data obtained earlier
Validation / Act of confirming or verifying
Chapter 12
Actual nursing diagnosis / Problems validated by the presence of major defining characteristics and possessing four components: label, definition, defining characteristics and related factor
Collaborative problems / Actual or potential health problem that may occur from complications of disease, diagnostic studies or the treatment regimen; the nurse works together with other members of the health care team toward its resolution
Cue / Significant information that is helpful in making decisions
Data cluster / Grouping of patient data or cues that points to the existence of a patient health problem
Diagnosing / Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
Diagnostic error / Failure to detect an actual unhealthy behavior or condition
Health problem / Condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted
Medical diagnoses / Statements about a specific disease process using terminology from a well-developed classification system accepted by the medical profession
Nursing diagnoses / Actual or potential health problem that an independent nursing intervention can prevent or resolve. Actual problem is present. Possible problem may be present, but more data are needed to confirm or disconfirm the problem. Potential problem may occur; defining characteristics are present as risk factors
Possible nursing diagnoses / Statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem
Risk nursing diagnoses / Clinical judgements that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation
Standard / Acceptable, expected level of performance established by authority, custom or consent
Syndrome nursing diagnoses / Cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation
Wellness diagnoses / Clinical judgement about an individual, family or community in transition from a specific level of wellness to a higher level of wellness
Chapter 13
Clinical pathways (critical pathways, care maps) / Case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient’s stay
Computerized plans of nursing care / Plans of patient care developed by computer software programs that enable the nurse to call up screens listing causes, goals and related nursing interventions for nursing diagnoses and medical diagnoses
Consultation / Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solutions
Criteria / Specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior
Discharge planning / Systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care
Expected outcomes / Specific, measurable criteria used to evaluate whether the patient goal has been met
Goal / An aim or an end
Initial planning / Planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care
Kardex care plan / Original filing system for nursing records and orders that was held centrally on the ward and contained all the nursing details and observations of patients that had been acquired during their stay in the hospital
Nursing intervention / Any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated and collaborative interventions
Nursing interventions classifications (NIC) / First comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions
Nursing outcomes classifications (NOC) / Developed by the Iowa Outcomes Project and present the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing interventions
Ongoing planning / Planning carried out by any nurse who interacts with the patient to keep the plan up-to-date, to facilitate the resolution of health problems, to manage risk factors and to promote function
Outcome identification / Observation of the patient to demonstrate the resolution of the problems identified by the nursing diagnoses and general problem list, along with the time frame for accomplishing these outcomes
Plan of nursing care / Written guide that directs the efforts of the nursing team as the nurses work with patients to meet health goals; it specifies nursing diagnoses, outcomes and associated nursing interventions
Planning / The act or process of making a plan to achieve or do something
Standardized care plans / Prepared plan of care that identifies the nursing diagnoses, patient goals and related nursing orders common to a specific population (e.g., normal neonates) or problem
Chapter 14
Collaborative interventions / Interdependent nursing actions performed jointly by nurses and other members of the health care team
Delegation / The transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome
Evidence-based practice / Nursing care provided that is supported by sound scientific rationale
Implementing / Carry out the plan of care
Nurse-initiated intervention / A treatment initiated by a nurse in response to a nursing diagnoses
Nursing intervention / Any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes; there are nurse-initiated, physician-initiated and collaborative interventions
Physician-initiated intervention / A treatment initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician’s order
Protocols / Written plan that details the nursing activities to be executed in specific situations
Standing orders / Document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities
Unlicensed assistive personnel (UAP) / Individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse
Chapter 15
Concurrent evaluation / The evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews and chart review to determine whether thee specified evaluative criteria are met
Criteria / Specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior
Nursing audit / A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care
Outcome evaluation / Evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care
Peer review / Evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care
Performance improvement / Commitment to healthier patients, quality care, reduced costs and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change and assessing the change to see if the goal is met
Process evaluation / Evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process
Quality-assurance program / Ongoing evaluation program designed and implemented to secure the excellence of health care; may involve an assessment of structure, process and outcome standards
Quality improvement / The commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes – also known as continuous quality improvement (CQI) or total quality management (TQM)
Retrospective evaluation / Evaluation of nursing care and patient outcomes after the patient has been discharged using post discharge questionnaires, patient interviews or chart review to collect data
Standards / Rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurse, the patient and the institution where health care is given
Structure evaluation / Focuses on the environment in which care is provided; also known as an audit
Chapter 16
Change-of-shift report / Communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped
Charting by exception (CBE) / Shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
Collaborative pathway / Case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions
Confer / To consult with someone to exchange ideas or to seek information, advise or instructions
Consultation / Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution
Critical pathway / Also known as critical paths, clinical pathways or care paths, are management plans that display goals for patients and provide the sequence and timing of actions necessary to achieve these goals with optimal efficiency
Discharge summary / Description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals
Documentation / Written, legal record of all pertinent interventions with the patient-assessments, diagnoses, plans, interventions and evaluations
Electronic medical record (EMR) / A digital version of a paper chart that contains a patient’s medical history from one practice; used for diagnosis and treatment
Flow sheet / Graphic record of abbreviated aspects of the patient’s condition
Focus charting / A documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format
Graphic sheet / Summary of several changing factors, especially the patient’s vital signs or weight and the treatments and medications given
Incident report / Or accident report, is a form that is filled out in order to record details of an unusual event that occurs at the facility, such as an injury to a patient
Minimum data set / A standard established by health care institutions that specifies the information that must be collected from every patient
Narrative notes / Progress notes written by nurses in a source-oriented record
Nursing informatics / Specialty that integrates nursing science, computer science and information science to manage and communicate data, information and knowledge in nursing practice
OASIS / Outcome and Assessment Information Set is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)
Patient record / A compilation of a patient’s health information; the patient record is the only permanent legal document that details the nurse’s interactions with the patient
Personal health record (PHR) / Information sheets that contain the individuals medical history, including diagnoses, symptoms and medications
PIE charting / Documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P) – intervention (I) – evaluation (E) format, and evaluated each shift
Problem-oriented medical record (POMR) / Documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care and progress notes
Progress notes / Any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes
Referral / Process of sending or guiding someone to another source for assistance
SBAR communications / Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication
SOAP format / Method of charting narrative progress notes; organizes data according to subjective info (S), objective info (O), assessment (A) and plan (P)
Source-oriented record / Documentation system in which each health care group records data on its own separate form
Variance charting / A report of any event that isn’t consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee or visitor