The Nursing Process & Pharmacology-Evolve Chpt. 4
critical care pathway
a standardized care plan that is derived from 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
drug history
history of drugs; used to evaluate the patient's need for medication, to obtain his or her current and past use of OTCs, prescriptions, herbal products, and street drugs, and to identify risk factors such as allergies to certian medications
tertiary sources
literature search
defining characteristics
manifestations or signs and symptoms that relate to a particular patient problem
multidisciplinary team
members who provide valuable clinical expertise, a holistic approach, and collaboration for the health care of individual patients
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
dependent actions
performed by the nurse on the basis of the health care provider's orders
secondary sources
relatives, significant others, medical records, laboratory reports, nursing notes, other care professionals
nursing diagnosis
second phase of the five step nursing process; uses clinical judgment about individual, family, or community responses to actual or potential health problems/life processes
medical diagnosis
statement of the patients alterations in structure and function, and this results in the diagnosis of a disease or disorder that impairs normal physiologic function
assessment
the first phase of the five step nursing process; starts when the patient is admitted and continuous until the patient is discharged from care; problem-identifying
nursing process
the foundation for the clinical practice of nursing and provides the framework for consistent nursing actions and involves the use of a problem-solving approach rather than an intuitive approach
evidence-based practice
the incorporation of evidence from research, clinical expertise and patient preferences into decisions about the health care of individual patients
collaborative problem
the nurse must decide whether the definitive interventions can be ordered to prevent or treat the problem to maintain the health status of the patient
focused assessment
the process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis
planning
third phase of the five step nursing process; plans should be formulated to meet the patient's needs
independent actions
those 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
drug monographs
used for each prescribed drug
nursing actions
what the nurse does
patient goals
what we want the patient to do
nursing care plan
written or computer-generated document that evolves from this planning process
implementation
consists of carrying out the established plan of care
nursing orders
describe how specific actions will be implemented for an individual patient
nursing classification systems
designed to provide a standardized language for reporting and analyzing nursing care delivery that has been individualized for the patient