Term
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Definition
| a framework on which to organize individualized nursing care |
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Term
| another term for subjective data is |
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Definition
| symptoms, which cant be oserved or measured-must come from pt |
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Term
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Definition
| observed and measurable by people other than the pt |
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Term
| secondary source to get information include |
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Definition
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Term
| two methods of collecting data is |
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Definition
| the interview and physical exam |
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Term
| actual nursing dx respresents |
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Definition
| a condition that is currently present |
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Term
| "risk for nursing dx" are those that |
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Definition
| the pt is susceptible to but not yet trouble by |
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Term
| a useful framework to guide prioritization is |
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Definition
| maslows hierarchy of needs |
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Term
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Definition
| actions the nurse may begin independently |
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Term
| nursing orders are necessary to provide |
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Definition
| instruction for all caregivers |
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Term
| implementation is the nurse |
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Definition
| carrying out nursing orders to promote outcome achievement |
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Term
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Definition
| signed, dated and have specific designation to who will perform intervention and specifics about time of frequency of the intervention |
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Term
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Definition
| when projected outcomes in not met |
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Term
| the nurse organized data and those that are related are called |
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Definition
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Term
| focues assessments are performed |
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Definition
| continously throughout nurse-pt contact based on the nursing care plan |
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Term
| data clusters assist the nurse to |
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Definition
| determine nursing diagnosis |
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Term
| a head to toe format proveds a |
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Definition
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Term
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Definition
| basis for developing nursing interventions |
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Term
| risk factors are those that increase |
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Definition
| the susceptibilty of a pt to a problem |
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Term
| the label of an actual nursing dx is |
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Definition
| connected to the asessed cauesd by r/t |
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Term
| a possible nursing dx requires |
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Definition
| additional data to confirm a problem or complete a data cluster so that it can be related to a NANDA label |
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Term
| during the planning phase |
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Definition
| the nurse connects interventions to nursing orders |
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Term
| plans are more effective when |
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Definition
| the pt is involved in the process |
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Term
| the nursing dx isnt evaluated what is |
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Definition
| the pt progress toward the outcome is |
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Term
| expected outcomes must be |
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Definition
| pt-centered, measuable, and refer to a time fram |
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Term
| when is an incident report filled out |
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Definition
| when pt care was not cobsistent with faciltiy or national standards |
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Term
| an incedent report explains what events |
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Definition
| time, extent of jinjury and who was notified |
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Term
| what is done when charging by exception |
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Definition
| additional tx, changed in pts condition, and new concers during the shift |
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Term
| institutions are reimnursed only for |
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Definition
| pt care that is documented-nothing can protect a person from litigation |
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Term
| critical pathways allow staff from all disciples to |
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Definition
| develop integrated care plans for a projected length of stay for pts of specific case type |
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Term
| home health care documentation has unique problems because |
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Definition
| of the need of different health care workers to access the medical record |
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Term
| OBRA was a significant Medicare and Medicaid legislation for |
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Definition
| long-term health care documentation |
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Term
| the nurse shouldnt read the medical record unless |
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Definition
| there is a clinical reason to do so |
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Term
| documentation is part of what phase of the nursind process |
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Definition
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Term
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Definition
| closes the computer file that was opened with the nurses password |
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Term
| ownership of the medical record belongs to |
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Definition
| the institution in the case of a hospitalized pt, or teh doctor in the case of provate office visits |
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Term
| POMR uses the acronym SOAPE in |
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Definition
| format and focused charting on a list of pt problems/nursing dx |
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Term
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Definition
| evaluates care services and results against accepted standards |
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