Pharmacology: Chapter 4 Vocabulary
Collaborative Problem
A statement that is worded as a potential complication. Abbreviated as *PC*
Anticipated Therapeutic Statements and Expected Outcome statements
Developed to document the effectiveness of the care delivered.
Objective Data
Gained from observations that the nurse makes with he use of physiological parameters.
Patient Goals
Goals that are accomplished due to the involvement of the patient.
Tertiary Sources
Provide an accurate depiction of the characteristics of a disease; the nursing interventions and diagnostic tests used; the pharmacologic treatment prescribed; the dietary interventions and physical therapy undertaken; and other factors pertinent to the patient's care requirements
Secondary Sources
Relatives, significant others, medical records, laboratory tests, nursing notes, other health care professionals. .
Assessment
The first phase of the five-step nursing process. Starts when the patient is admitted and continues until the patient is discharged from care. Known as the *problem-identifying* stage.
Nursing process
The foundation for the clinical practice of nursing. It provides the framework for consistent nursing actions and involves the use of a problem-solving approach When implemented properly, it also provides a method for evaluating the outcomes of the therapy delivered. Provides a scientific, transferrable method for health care planners to assign nursing staff to patients and to determine and justify the cost of providing nursing care.
Implementation
The fourth phase of the nursing process and it consists of carrying out the established plan of care.
Evidence-based Practice
The incorporation of evidence from research, clinical expertise and patient preferences into decisions about the health care of individual patients.
Primary Source
The patient
Focused Assessment
The process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis.
Critical Care Pathway
A standardized care plan that is derived from the best practice patterns and that enables the nurse to develop a treatment plan that sequences detailed clinical interventions to be performed over a projected amount of time for a specific case type or disease process.
Medical Diagnosis
A statement of the patient's alterations in structure and function, and this results in the diagnosis of a disease or disorder that impairs normal physiologic function
Dependent Actions
Actions performed by the nurse on the basis of the health care provider's orders
Common Adverse Effects
Common side effects
Nursing Orders
Describe how specific actions will be implemented for an individual patient
Drug Monographs
Helps to identify problems related to medication therapy
Defining Characteristics
Manifestations or signs and symptoms
multidisciplinary team
Members who provide clinical expertise, a holistic approach, and collaboration for the health care of individual patients.
Adverse Effects
Most commonly observed problems associated with drug treatment of a disease
Independent Actions
Nursing actions that are not prescribed by a health care provider that a nurse can provide by virtue of the education and licensure that he or she has attained.
Interdependent Actions
Nursing actions that the nurse implements cooperatively with other members of the health care team for restoring or maintaining the patient's health.
Priority Setting
Organizing patient's needs in relation to their direct effects ion the maintenance of homeostasis.
Subjective Data
Pieces of information provided by the patient
Serious Adverse Effects
Serious / Life threatening side effects
Measurable Goal Statement
Starts with an action word that is followed by the behavior or behaviors to be performed by the patient or the patient's family.
Nursing Actions
Suggested by the etiology of the problems identified in the nursing diagnoses, and they are used to implement plans.
Nursing classification systems
Systems designed to provide a standardized language for reporting and analyzing nursing care delivery that has been individualized for the patient. Promote input from multidisciplinary team members. Measure and validate the impact of actual nursing diagnoses and interventions on outcomes for patients, families, and communities.
Planning
The Third phase of the five-step nursing process. Formulating plans to meet the patient's needs.
Therapeutic Intent
The reason the drug is prescribed and what symptoms should go away.
Nursing Diagnosis
The second phase of the five-step nursing process. According to NANDA it is: a clinical judgment about individual, family, or community responses to actual health problems/ life processes.
Nursing Care Plan
The written or computer-generated document that evolves from the planning process
Drug History
Used to (1) evaluate the patient's need for medication, (2) to obtain his or her current and past use of over-the-counter medications, prescription medications, herbal medications, and street drugs, (3) to identify problems related to drug therapy.
Nursing Interventions
What the nurse does during the Implementation stage