Glossary

ADOPIE: An easy way to remember the ANA Standards and the nursing process. Each letter refers to the six components of the nursing process: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation. (Chapter 4.2)

Art of nursing: Unconditionally acceptance of the humanity of others, respecting their need for dignity and worth, while providing compassionate, comforting care.^[1] (Chapter 4.2)

At-risk populations: Groups of people who share a characteristic that causes each member to be susceptible to a particular human response, such as demographics, health/family history, stages of growth/development, or exposure to certain events/experiences.^[2] (Chapter 4.4)

Associated conditions: Medical diagnoses, injuries, procedures, medical devices, or pharmacological agents. These conditions are not independently modifiable by the nurse, but support accuracy in nursing diagnosis.^[3] (Chapter 4.4)

Care relationship: A relationship described as one in which the whole person is assessed while balancing the vulnerability and dignity of the client and family.^[4] (Chapter 4.2)

Client: Individual, family, or group, which includes significant others and populations.^[5] (Chapter 4.2)

Clinical judgment: The observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.^[6] (Chapter 4.2)

Clinical reasoning: A complex cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and weigh alternative actions. ^[7] (Chapter 4.2)

Clustering data: Grouping data into similar domains or patterns. (Chapter 4.4)

Collaborative nursing interventions: Nursing interventions that require cooperation among health care professionals and unlicensed assistive personnel (UAP). (Chapter 4.6)

Coordination of care: While implementing interventions during the nursing process, includes competencies such as organizing the components of the plan with input from the health care consumer, engaging the client in self-care to achieve goals, and advocating for the delivery of dignified and person-centered care by the interprofessional team.^[8] (Chapter 4.7)

Critical thinking: Reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.^[9] (Chapter 4.2)

Cues: Subjective or objective data that gives the nurse a hint or indication of a potential problem, process, or disorder. (Chapter 4.2)

Deductive reasoning: “Top-down thinking” or moving from the general to the specific. Deductive reasoning relies on a general statement or hypothesis—sometimes called a premise or standard—that is held to be true. The premise is used to reach a specific, logical conclusion. (Chapter 4.2)

Defining characteristics: Observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis, or syndrome. This does not only imply those things that the nurse can see, but also things that are seen, heard (e.g., the client/family tells us), touched, or smelled.^[10] (Chapter 4.4)

Delegation: The assignment of the performance of activities or tasks related to client care to unlicensed assistive personnel while retaining accountability for the outcome.^[11] (Chapter 4.7)

Dependent nursing interventions: Interventions that require a prescription from a physician, advanced practice nurse, or physician’s assistant. (Chapter 4.6)

Direct care: Interventions that are carried out by having personal contact with a client. (Chapter 4.6)

Electronic Medical Record (EMR): An electronic version of the client’s medical record. (Chapter 4.3)

Evidence-Based Practice (EBP): A lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories; clinical expertise and evidence from assessment of the health care consumer’s history and condition, as well as health care resources; and client, family, group, community, and population preferences and values.^[12] (Chapter 4.2)

Expected outcomes: Statements of measurable action for the client within a specific time frame and in response to nursing interventions. “SMART” outcome statements are specific, measurable, action-oriented, realistic, and include a time frame. (Chapter 4.5)

Functional Health Patterns: An evidence-based assessment framework for identifying client problems and risks during the assessment phase of the nursing process. (Chapter 4.4)

Generalization:  A judgment formed from a set of facts, cues, and observations. (Chapter 4.2)

Goals: Broad statements of purpose that describe the aim of nursing care. (Chapter 4.5)

Health promotion-wellness nursing diagnosis: A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. (Chapter 4.4)

Health teaching and health promotion: Employing strategies to teach and promote health and wellness.^[13] (Chapter 4.7)

Hypothesis: A proposed explanation for a situation. It attempts to explain the “why” behind the problem that is occurring. (Chapter 4.2)

Independent nursing interventions: Any intervention that the nurse can provide without obtaining a prescription or consulting anyone else. (Chapter 4.6)

Indirect care: Interventions performed by the nurse in a setting other than directly with the client. An example of indirect care is creating a nursing care plan. (Chapter 4.6)

Inductive reasoning: A type of reasoning that involves forming generalizations based on specific incidents. (Chapter 4.2)

Inference: Interpretations or conclusions based on cues, personal experiences, preferences, or generalizations. (Chapter 4.3)

Licensed Practical Nurses or Licensed Vocational Nurses (LPNs/LVNs): Nurses who have had specific training and passed a licensing exam. The training is generally less than that of a Registered Nurse. The scope of practice of an LPN/LVN is determined by the facility and the state’s Nurse Practice Act. (Chapter 4.3)

Maslow’s Hierarchy of Needs: A theory used to prioritize the most urgent client needs to address first. The bottom levels of the pyramid represent the most important physiological needs intertwined with safety. (Chapter 4.4)

Medical diagnosis: A disease or illness diagnosed by a physician or advanced health care provider such as a nurse practitioner or physician’s assistant. Medical diagnoses are a result of clustering signs and symptoms to determine what is medically affecting an individual. (Chapter 4.3)

Nursing: Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in the recognition of the connection of all humanity.^[14] (Chapter 4.2)

Nursing care plan: Specific documentation of the planning and delivery of nursing care that is required by The Joint Commission. (Chapter 4.2)

Nursing diagnosis: A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community. (Chapter 4.4)

Nursing interventions: Evidence-based actions that the nurse performs to achieve client outcomes. (Chapter 4.6)

Nursing process: A systematic approach to client-centered care with steps including assessment, diagnosis, outcome identification, planning, implementation, and evaluation; otherwise known by the mnemonic “ADOPIE.” (Chapter 4.1)

Objective data: Data that the nurse can see, touch, smell, or hear or is reproducible such as vital signs. Laboratory and diagnostic results are also considered objective data. (Chapter 4.3)

Order: An intervention, remedy or treatment as directed by an authorized primary health care provider.^[15] (Chapter 4.6)

Outcome: A measurable behavior demonstrated by the client’s response to nursing interventions.^[16] (Chapter 4.5)

PES format:  The format of a nursing diagnosis statement that includes:

• Problem (P) – statement of the client problem (i.e., the nursing diagnosis)
• Etiology (E) – related factors (etiology) contributing to the cause of the nursing diagnosis
• Signs and Symptoms (S) – defining characteristics manifested by the client of that nursing diagnosis (Chapter 4.4)

Physical examination: A systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion. (Chapter 4.3)

Prescription: Intervention as it relates to medication specifically as directed by an authorized primary health care provider.^[17] (Chapter 4.6)

Primary data: Information collected from the client. (Chapter 4.3)

Primary health care provider: Member of the health care team (usually a medical physician, nurse practitioner, etc.) licensed and authorized to formulate prescriptions on behalf of the client.^[18] (Chapter 4.6)

Prioritization: The skillful process of deciding which actions to complete first for client safety and optimal client outcomes. (Chapter 4.4)

Problem-focused nursing diagnosis: A clinical judgment concerning an undesirable human response to health condition/life processes that exist in an individual, family, group, or community. (Chapter 4.4)

Quality improvement: The “combined and unceasing efforts of everyone — health care professionals, clients and their families, researchers, payers, planners, and educators — to make the changes that will lead to better client outcomes (health), better system performance (care), and better professional development (learning).”^[19] (Chapter 4.7)

Rapport: Developing a relationship of mutual trust and understanding. (Chapter 4.2)

Registered Nurse (RN): A nurse who has had a designated amount of education and training in nursing and is licensed by a state Board of Nursing. (Chapter 4.3)

Related factors: The underlying cause (etiology) of a nursing diagnosis. (Chapter 4.4)

Risk nursing diagnosis: A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. (Chapter 4.4)

Secondary data: Information collected from sources other than the client. (Chapter 4.3)

Subjective data: Data that the client or family reports or data that the nurse makes as an inference, conclusion, or assumption, such as “The client appears anxious.” (Chapter 4.3)

Syndrome nursing diagnosis: A clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. (Chapter 4.4)

Unlicensed Assistive Personnel (UAP): Any unlicensed personnel trained to function in a supportive role, regardless of title, to whom a nursing responsibility may be delegated.^[20] (Chapter 4.3)