| Assessment | A systematic, dynamic way collect and analyze data about a client the first step in delivering nursing care |
| Biographic data | Provide info about the facts or events in a person’s life |
| Case management | Encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for patient. |
| Clinical pathway | A multidisciplinary plan that incorporates EBP guidelines for high-risk, high-volume, high-cost types of cases while providing the optimal patient outcome and maximizing clinical efficiency |
| Collaborative problems | Health-related problems that the nurse anticipates based on condition or diagnosis of patient |
| Cue | A piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur |
| Database | A large store or bank of info(for the patient) |
| Defining characteristics | The clinical cues, signs, and symptom's that furnish evidence that the problem exists |
| Diagnose | To identify the type the type and cause of health condition |
| Evaluation | A determination made about the extent to which the established goals have been achieved |
| Goal | The purpose to which an effort is directed |
| Implementation | Phase of the nursing process, the nurse and other members of the team put the established plan into action to promote goal achievement (fifth phase of nursing process) |
| Managed care | Refers to healthcare systems that have control over primary health care services and attempt to trim down health care costs by reducing unnecessary or overlapping services |
| Medical diagnosis | identification of a disease or
condition with the evaluation of physical signs, sympr
toms, patient interviews, laboratory tests, diagnostic
procedures, review of medical records, and patient hise
tory |
| NANDA-I | to reflect nursing diagnosis terminology used atound the world. |
| Nursing diagnosis/patient problem statement | is a type of health problem that can be identified by the
nurse |
| Nursing interventions | are those activities that promote the achievement of the desired patient goal |
| Nursing process | a systematic method by which nurses plan and provide care for patients |
| Nursing-sensitive patient outcomes | Identification of outcomes that are responsive to nursing care is important work for nursing, especially in connection with efforts to ,
contain costs and establish best practices |
| Objective data | are observable and measurable signs |
| Outcome(goal) | These classification systems, further provide research-based information regarding nursing treatments and judgments |
| Planning | phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the patient problem
statement. |
| Potential patient problem statement | are written as two part statements: (1) the patient problem statement withthe adjective"potential" in front of it, and (2) the risk
factor(s). |
| Standardize language | terms that have the same definition and meaning regardless of who uses them |
| Subjective data | are information that is provided by the patient |
| Variance | Unexpected event that occurs during the use of a clinical pathway (can be positive or negative) |
