13.6: Key Terms

Fundamentals of Nursing · LibreTexts

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    clinical pathway
    evidence-based practice guideline used to develop plans of care
    collaborative problem
    a problem that requires interdisciplinary team members to complete
    core measure
    evidence-based standard of care or practice guideline established by The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS)
    defining characteristic
    the actual sign or symptom being exhibited by the problem
    diagnostic error
    a failure to identify a response as unhealthy
    establishing priorities
    the means of identifying what steps need to be implemented first and why
    etiology
    the cause (or causes) of a specific disease state
    health promotion diagnosis
    a diagnosis that can help promote and improve the overall well-being and health of a patient and/or their family/support structure/community
    medical diagnosis
    identification of a disease or a condition and a description of a problem toward which providers direct the treatment plan
    NANDA-I
    an organization whose purpose is to facilitate the development, modification, distribution, and use of standardized nursing diagnostic terminology
    nursing diagnosis
    a method to provide and evaluate appropriate patient care
    nursing process
    a five-step method to guide decision-making for nurses
    outcome
    the desired result or goal after implementation of the patient’s individualized plan of care
    problem-focused diagnosis
    an unwanted response to a health condition
    refine the nursing diagnosis
    to select a new diagnosis, or narrow an existing diagnosis down more specifically, to assign new interventions based on outcomes
    related factor
    the reason derived from the etiology or pathophysiology of the disease process or condition
    risk diagnosis
    a diagnosis behind the signs and symptoms the patient is experiencing; developed through clinical judgment based on the vulnerability of the patient’s individualized situation
    Standards of Practice
    standards designed by the ANA and based on the nursing process that provides a problem-solving-focused approach to nursing practice
    syndrome diagnosis
    a diagnosis that occurs when a group or cluster of nursing diagnoses can all be utilized based on certain life events or situations
    Tanner’s Clinical Judgement Model (CJM)
    a framework that offers a different articulated perspective to the problem-solving approach of developing nursing diagnosis
    taxonomy
    a system of classification
    Taxonomy II
    the current classification method for listing nursing diagnosis; it has three levels: domains, classes, and nursing diagnosis
    validate
    to confirm the chosen diagnosis is appropriate for the individual patient using evidence to support the diagnosis

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