Exam 2 Vocab

analytics - discovery, interpretation, and communication of meaningful patterns in data concurrent evaluation - the evaluation of nursing care and patient outcomes while the patient is receiving care, conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met clinical inquiry - ongoing process of questioning and evaluating practice and advancing informed practice clinical pathways - case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay collaborative problem - actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution blended competencies - the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing aggressive behavior - standing up for one's rights in a negative manner that violates the rights of others cultural assimilation - process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different caring - moral imperative that guides nursing praxis (education, practice, and research); action and competencies that aim toward the good and welfare of others basic research - research designed to generate and refine theory; the findings are often not directly useful in practice cultural blindness - the process of ignoring differences in people and proceeding as though the differences do not exist assertive behavior - ability to stand up for oneself and others using open, honest, and direct communication collaborative interventions - interdependent nursing actions performed jointly by nurses and other members of the health care team delegation - the transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome change-of-shift report - communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped big data - accumulation of data from various sources, combined with new technologies that allow for the transformation of data to information clinical judgment - refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes concept - abstract images (ideas) that are formed as impressions from the environment and organized into symbols of reality cultural competence - care delivered with an awareness of the aspects of the patient's culture evaluating - measurement of the extent to which the patient has achieved the goals specified in the plan of care; factors that positively or negatively influence goal achievement are identified, and the plan of care is terminated or revised data cluster - grouping of patient data or cues that points to the existence of a patient health problem conceptual framework - set of concepts, along with the statements that arrange the concepts into an understandable pattern cultural diversity - (1) coexistence of different ethnic, biological sex, racial, and socioeconomic groups within one social unit; (2) diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, biological sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location clinical reasoning - a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking diagnosing - analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve evaluative statement - a judgment summarizing the nurse's findings after data have been collected and interpreted to determine patient outcome achievement confer - to consult with someone to exchange ideas or to seek information, advice, or instructions data visualization - presentation of data in a pictorial or graphical format diagnostic error - failure to detect an actual unhealthy behavior or condition cultural imposition - tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group concept mapping - instructional strategy that requires learners to identify, graphically display, and link key concepts criteria - specified behavior; for example, the measurable criteria in a patient goal specifies how the patient must perform the desired behavior evidence-based practice - nursing care provided that is supported by sound scientific rationale consultation - process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution implementing - carry out the plan of care creative thinking - a process involving imagination, intuition, and spontaneity—factors that underpin the art of nursing deductive reasoning - cognitive process in which one examines a general idea and then considers specific actions or ideas cultural respect - enables nurses to deliver services that are respectful of and responsive to the health beliefs, practices, and cultural and linguistic needs of diverse patients; critical to reducing health disparities and improving access to high-quality health care cliché - a stereotyped, trite, or pat answer discharge planning - systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care health problem - condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted indirect care intervention - treatment performed away from the patient but on behalf of a patient or group of patients National Database of Nursing Quality Indicators (NDNQI) - ANA-funded database of nursing-sensitive quality indicators aimed at promoting and facilitating the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes critical/collaborative pathway - case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions genomics - (1) study of the structure and interactions of all genes in the human body, including their interactions with each other as well as the environment; (2) emerging discipline in which genomic information about a person is used in their clinical care (e.g., for diagnostic or therapeutic decision making) health promotion nursing diagnosis - behavior of an individual motivated by a personal desire to increase well-being and health potential culture - sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group communication - process of sharing information; process of generating and transmitting meanings critical thinking - thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned; a systematic way to form and shape one's thinking that functions purposefully and exactingly evidence-based practice (EBP) - nursing care provided that is supported by sound scientific rationale expected outcome - specific, measurable criteria used to evaluate whether the patient goal has been met nursing-sensitive quality indicators - indicators specific to nursing that identify structures of care and care processes that influence care outcome discharge summary - description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals health information technology (IT) - standard and agreed upon terms used in an electronic health record to improve data trending and sharing; ANA approved nursing terminologies include those listed in Table 20-5 medical diagnosis - statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession culture conflict - situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values CUS (communication tool) - communication tool to assist in effective communication related to patient safety concerns; the acronym CUS stands for I'm Concerned, I'm Uncomfortable, This is unSafe (or This is a Safety issue) critical thinking indicators - evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice evidence-based practice guideline - guideline guidelines written by a panel of experts that synthesize information from multiple studies and recommend best practices to treat patients with a disease, a symptom, or a disability goal - an aim or an end protocols - written plan that details the nursing activities to be executed in specific situations outcome evaluation - evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care documentation - written, legal record of all pertinent interventions with the patient— assessments, diagnoses, plans, interventions, and evaluations informatics: - inductive reasoning - cognitive process in which one identifies a specific idea or action and then makes conclusions about general ideas culture shock - those feelings, usually negative, a person experiences when placed in a different culture empathy - (1) objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting oneself in another person's circumstances and imagining what it would be like to share that person's feelings; (2) intellectually identifying with the way another person feels decision making - purposeful, goal-directed effort applied in a systematic way to make a choice among alternatives initial planning - planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care nursing diagnosis - actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; and potential problem may occur); defining characteristics are present as risk factors standing orders - document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities peer review - evaluation at the closest point to the patient and an ongoing tool to use for professional growth electronic health record (EHR) - digital version of a patient's chart that may contain the patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory and test results interoperability - ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user informed consent - knowledgeable, voluntary permission obtained from a patient to perform a specific test or procedure ethnicity - sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns problem-focused nursing diagnosis: - intuitive problem solving - direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible feedback - verbal and nonverbal evidence that the message is received and understood nurse-initiated intervention - independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs performance improvement - commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met flow sheet - graphic record of abbreviated aspects of the patient's condition (e.g., vital signs, routine aspects of care) meaningful use - the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid unlicensed assistive personnel (UAPs) - individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse nursing process - five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating ethnocentrism - belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs group dynamics - study of a group's characteristics and ways of functioning nursing research - encompasses both research to improve the care of people in the clinical setting and to study people and the nursing profession, including education, policy development, ethics, and nursing history risk nursing diagnosis - clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation nursing care plan - written guide to direct the efforts of the nursing team as they work with the patient to meet health goals; specifies prioritized nursing diagnoses, patient goals, and nursing orders process evaluation - evaluation focusing on the nature and sequence of activities carried out by nurses implementing the nursing process focus charting - a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format nurse informaticist - specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice nursing theory - differentiates nursing from other disciplines and activities by serving the purposes of describing, explaining, predicting, and controlling desired outcomes of nursing care practices