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clarity
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being easily understood in thought and style
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clustering
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invlolves organizing pt assessment data into groups with similar underlying causes
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secondary data
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obtained from pt family, friends, or other healthcare providers
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risk fators
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environmental, physical, physiological, or situational concerns that increase a pts vulnerability to a potential problem
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outcome indicators
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criteria by which goal attainment is observed or measured
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nursing diagnosis
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identification of actual or potential health problems or life processes and responses to a problem
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diagnosis label
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a concise term or phase that represents a pattern of related, clustered data
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deductive reasoning
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involves generating facts or details from a major theory, generalization, or premise (general to specific)
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taxonomy
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an effective unified language classification system
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short term goals
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achievable in less than a week
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steps of the nursing process
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A: assessment
D: diagnosis
P: planning
I: intervention
E: evaluation
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long term goals
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goals that take weeks or months
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palpation
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uses touch to assess body organ, skin, texture, temp, moisture, turgor, tendernes, and thickness
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related factors
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the underlying cause or etiology of a pts problem
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auscultation
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technique of listening with stethoscope to the organs
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actual nursing diagnosis
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identify existing problems or concerns of a pt
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primary data
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directly from the pt
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inferences
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conclusion
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Accuracy
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representing something in a true and correct way
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nursing interventions classification
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A comprehensive, research-based, standardized, collection of interventions and associated activites
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health promoting nursing diagnosis
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used in situations in which pts express interest in improving their health through a positive change in behavior
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cue
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hint or indication of a potential disease or disorder
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bias
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an inclination or tendency to favoritism or partiality
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inductive reasoning
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uses specific facts or details to make conclusions and generalizations (specific to general)
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subjective data
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spoken infro or symptoms that cant be authenticated
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dependent nursing interventions
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require Dr order
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inspection
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the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems
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defining characteristics
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cues/clusters of related assessment data that are signs, symptoms, or indications of an actual or health promoting nursing diagnosis
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validation
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process of gathering info to determine whether the info or data collected are factual and true
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traige
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form of emergency assessment
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nursing outcomes classification
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standardized vocab used for describing pt outcomes
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risk nursing diagnosis
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apply when there is an increased potential or vulnerability for a pt to develop a problem
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implementation
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consist of performing a task and documentation of each intervention
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clinical reasoning
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uses critical thinking, knowledge, and experience to develop solutions to problems and make decisions in a clinical setting
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breadth
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considering a topic, problem, or issue from every relevant viewpoint
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evaluation
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focuses on pts and pt response to nursing interventions and outcome attainment
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direct care
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interventions that are carried out by having personal contact with the pt
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independent nursing interventions
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doesnt require a Dr order
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percussion
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tapping the pts skin with short, sharp, strokes that cause a vibration to travel through the skin and to the upperlayers of the underlying structures
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indirect care
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includes nursing interventions that are performed to benefit pts but dont involve face to face contact
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objective data
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can be measured or observed (signs)
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