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