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