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