N302 Chapter 2

legal documents developed at the state level that define professional nursing's scope of practice and outline nurses' rights, responsibilities, and licensing requirements in providing care to individual clients, families, and communities.

a broad term that refers ot the legal and sthical boundaries of practice for professional nurses established by each stateand defined in written state statutes.

providing only that information needed to provide care for the client to other health professionals directly involved in the care of the client.

• giving the client enough information on which to base a knowledgeable decision. This is another legal aspect. For a legal consent to be valid, it must include these three things:
• 1. consent must be voluntary
• 2. the client must have full disclosure about hte risks, benefits, cost, potential side effects or adverse reactions, and otehr alternatives to treatment
• 3. the client must have the capacity and competency to understand the information and to make an informed choice.

• Health Insurance Portability and Accountability Act
• implemented in 2003. designed to protect the privacy of client records.

written statement or document executed by a competent adult that is designed to provide medical personnel, family members, and others with information as to hte person's wishes regarding the nature and extent of medical care to be provided in the future shoud he or she lose decision-making capacity.

refers to the client's perception of data and what the client says about the data.

refers to data that are directly obseravable or verifiable through physical examination or tests.

educated guess about the meaning of a behavior or statement. To make it factual, check it with the client.

• "the change in health status between a baseline time point and a final time point"
• should be client-centered and describe in specific, measureable terms.

• based on diagnoses
• documented in measureable terms
• developed collaboratively with the client an dother health providers
• realistic and achievable

interventions that nurses can provide without a physicians order or direction form another health professional. --ex: health education, health promotion strategies, and counseling

require an oral or a written order from a physician to implement.

Nursing interventions classification

nursing outcomes classification

NANDA, NIC, and NOC classifications

represent a standardized, integrated multidisciplinary care plan, which includes the assessment and care given by all disciplines involved with a client's care.