Key Terms
- 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