Fundamentals of Nursing: Evidence-Based Practice and the Nursing Process

Vocabulary practice flashcards covering fundamental nursing concepts including Evidence-Based Practice (EBP), the Clinical Judgment Measurement Model, and the five phases of the Nursing Process (ADPIE).

Evidence-based practice (EBP)

A problem-solving approach to clinical decision making that integrates the best available research evidence, clinician expertise, patient preferences and values, and available health-care resources.

Best evidence

Well-designed, systematically conducted research studies published in scientific, peer-reviewed journals.

PICOT format

A standard framework for formulating clinical research questions, standing for Patient/population ($P$), Intervention ($I$), Comparison ($C$), Outcome ($O$), and Time ($T$).

Critical appraisal

The systematic process of synthesizing research findings and judging their scientific rigor, clinical applicability, value, feasibility, and usefulness prior to changing nursing practice.

Critical thinking

A systematic and logical thinking process that involves questioning, reflecting on reasoning, and focusing on clinical issues to make decisions that generate positive patient outcomes.

Clinical judgment

The observable, definitive outcome of critical thinking and clinical decision making.

Clinical decision making

A core professional nursing function that separates professional clinical judgment from routine task performance carried out by assistive personnel.

Clinical judgment model

A sequential six-step cognitive process consisting of: Recognize cues, Analyze cues, Prioritize hypotheses, Generate solutions, Take action, and Evaluate outcomes.

Assessment

The first phase of the nursing process consisting of two core tasks: collecting data from primary and secondary sources, followed by interpreting and validating that data.

Primary source

The patient, who serves as the main and most accurate provider of direct assessment information when capable of giving reliable reports.

Secondary sources

Individuals and resources other than the patient who provide health data, including family members, caregivers, the medical record, diagnostic tests, and other health-care team members.

Subjective data

Information reported directly by the patient about their symptoms, feelings, perceptions, or self-reported experiences, including a numerical pain rating.

Objective data

Observable, measurable findings gathered by a healthcare provider through inspection, palpation, auscultation, diagnostic test results, or vital signs.

Data validation

The step of rechecking and confirming collected information when findings are abnormal, inconsistent, questionable, or conflicting with the overall patient profile.

Leading question

An interview technique or phrasing that suggests a desired answer to the patient, which introduces bias into the assessment data.

Medical diagnosis

The formal identification and labeling of a specific disease, condition, or pathological process by a licensed physician or advanced practice provider.

Nursing diagnosis

A clinical judgment concerning a human response to health conditions, life processes, or vulnerability that nurses are licensed and competent to identify and treat.

Collaborative problem

An actual or potential physiological complication that requires the joint management of nursing interventions and provider-directed medical orders.

Problem-focused diagnosis

A type of nursing diagnosis that addresses an existing, active undesirable human response supported by observable clinical findings and defining characteristics.

Risk diagnosis

A clinical judgment regarding the vulnerability of an individual to develop an undesirable human response that has not yet occurred, supported by risk factors rather than defining characteristics.

Health-promotion diagnosis

A clinical judgment reflecting a patient's readiness and motivation to improve their overall well-being and enhance specific health behaviors.

PES format

A three-part framework used to write diagnostic statements: Problem (nursing diagnosis label), Etiology (related factor), and Signs/Symptoms (defining characteristics).

Planning

The stage of the nursing process in which the nurse prioritizes patient problems, establishes measurable patient-centered goals and expected outcomes, and selects appropriate nursing interventions.

Expected outcome

A specific, measurable change in a patient's health status or behavior that is used to evaluate the effectiveness of nursing care.

SMART outcomes

A set of design criteria ensuring expected outcomes are Specific, Measurable, Attainable, Realistic, and Timed.

Implementation

The phase of the nursing process where planned interventions are initiated and carried out to achieve patient goals and expected outcomes.

Direct care

Nursing treatments and interventions performed through direct physical, interpersonal, or bedside interactions with the patient.

Indirect care

Nursing interventions performed away from the bedside on behalf of the patient, such as multidisciplinary communication, delegating tasks, and documenting.

Clinical practice guideline / protocol

A systematically developed, evidence-based recommendation that helps health-care providers make informed decisions about care for specific clinical circumstances.

Standing orders

Preprinted, authorized medical orders specifying treatments or medications that can be implemented for patients under clearly defined clinical criteria.

Evaluation

The phase of the nursing process where the nurse examines clinical data to compare actual patient responses against predetermined expected outcomes to determine if interventions were effective.

ADPIE

A mnemonic representing the five cyclical steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.