ADPIE Key Terms

  1. Clinical decision making
    Problem solving approach that nurses use to define pt problems and select appropriate treatment
  2. concept map
    care planning tool that assists in critical thinking and forming associations between a pt's ND and interventions
  3. Critical thinking
    active, purposeful, organized, cognitive processes used to carefully examine ones thinking and the thinking of others
  4. decision making
    Process involving critical appraisal of info that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking
  5. Diagnostic reasoning
    Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking
  6. evidence based knowledge
    Knowledge that is derived from the integration of best research, clinical expertise, and patient values
  7. inference
    Judgment or interpretation of informational cues. Taking one proposition as a given and guessing that another proposition follows.
  8. nursing process
    systematic problem solving method by which nurses individualize care for each pt. assessment, diagnosis, planning, implementation, evaluation.
  9. problem solving
    methodical systematic approach to explore conditions and develop solutions including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem
  10. Reflection
    Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking
  11. scientific method
    Codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas.
  12. Assessment
    activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.
  13. close ended question
    form of a question that limits pts answer to one or two words.
  14. cue
    information that a nurse acquires through hearing, visual observations, touch, and smell
  15. database
    bank of information that can be processed by a computer.
  16. functional health patterns
    method for organizing assessment data based on the level of patient function in specific areas.
  17. nursing health history
    data collected about a pts present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness
  18. objective data
    information that can be observed by others; free of feelings, perceptions, and prejudices
  19. open ended question
    form of question that prompts pt to answer in more than one or two words
  20. subjective data
    info gathered from pt statements; the pts feelings and perceptions. not verifiable by another except by inference.
  21. validation
    act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan
  22. back channeling
    includes active listening prompts such as, "all right, go on, uh huh"
  23. concomitant symptoms
    pt experiencing other symptoms along with the primary symptom. ex: nausea accompanied by pain
  24. Review of symptoms ROS
    is a systematic approach for collecting the pts self reported data on all body sysmptoms
  25. actual ND
    judgment that is clinically validated by the presence of major defining characteristics
  26. collaborative problem
    physiological complication that requires the nurse to use nursing and health care provider prescribed interventions to maximize patient outcomes
  27. data cluster
    set of signs and symptoms that are grouped together in logical order
  28. defining characteristics
    related signs and symptoms or clusters of data that support the ND
  29. etiology
    study of all factors that may be involved in the development of a disease
  30. Medical diagnosis
    formal statement of the disease entity or illness made by the physician or health care provider
  31. ND
    formal statement of an actual or potential health problem that nurses can legally and independently treat; the second step during which the pts actual and potential unhealthy responses to an illness or condition are identified.
  32. related factor
    any condition or event that accompanies or is linked with the pts health care problem
  33. risk ND
    Describes human responses to health conditions/ life processes that may develop in vulnerable pt
  34. clinical criterion
    is an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion
  35. health promotion nursing diagnosis
    a clinical judgment of pt motivation, desire, and readiness to increase well being and actualize human health potential as expressed in their readiness to enhance specific health behaviors.
  36. diagnostic label
    an approved name of the ND
  37. collaborative interventions
    therapies that require knowledge skill and expertise of multiple health care professionals
  38. consultation
    process in which the help of a specialist is sought to identify ways to handle problems in pt management or in planning and implementing programs
  39. critical pathway
    tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, pathway is used to manage the care of a pt throughout a projected length of stay
  40. planning
    process of designing interventions to achieve the goals and outcomes of health care delivery
  41. scientific rationale
    reason why a specific nursing action was chosen based on supporting literature
  42. priority setting
    the ordering of nursing diagnoses or pt problems using determinations of urgency to establish a preferential order for nursing actiions
  43. goal
    a broad statement that describes a desired change in a pts condition or behavior
  44. expected outcome
    a measurable criterion to evaluate goal achievement
  45. pt centered goal
    reflects a pts highest possible level of wellness and independence in funtion
  46. short term goal
    an objective behavior or response that you expect a pt to achieve in a short time usually less than a week
  47. long term goal
    objective behavior or response that you expect a pt to achieve over a longer period usually over several days weeks or months
  48. nursing sensitive patient outcome
    is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.
  49. independent nursing interventions
    actions nurses initiate. pertain to activities of daily living, health education and counseling
  50. dependent nursing interventions
    actions that require an order from a doctor
  51. nursing care plan
    includes ND, goals and expected outcomes, interventions and evaluations
  52. interdisciplinary care plans
    include contributions from all disciplines involved in pt care
  53. adverse reaction
    any harmful, unintended effect of medication, diagnostic test, or therapeutic intervention
  54. implementation
    initiation and completion of the nursing actions necessary to help the pt achieve health care goals
  55. instrumental activities of daily living IADL
    activities necessary for independence in society beyond eating grooming transferring and toileting. include such skills as shopping preparing meals, banking, and taking medications
  56. nursing intervention
    any treatment based on clinical judgment and knowledge that a nurse performs to enhance pt outcomes
  57. preventive nursing actions
    nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, and third health care
  58. standing order
    written and approved documents containing rules policies, procedures, regulations, and orders for the conduct of pt care in various stipulated clinical settings
  59. direct care
    interventions are treatments performed through interactions with pt
  60. indirect care
    interventions are treatments performed away from the pt but on the behalf of the pt or group of pts
  61. clinical practice guideline
    systematically developed set of statements that helps nurses and doctors man decisions about appropriate health care for specific clinical situaltions
  62. lifesaving measure
    physical care technique that you use when a pts physiological state is threatened
  63. patient adherence
    means that pts and families invest time in carrying out required treatments
  64. evaluation
    determination of the extent to which established pt goals have be achieved
  65. standard of care
    minimum level of care accepted to ensure high quality care to pt. standards of care define the types of therapies typically administered to pts with defined problems or needs
Author
athors766ns
ID
281773
Card Set
ADPIE Key Terms
Description
Critical thinking
Updated