Topic 5 - Clinical Judgment and the Nursing Process

Vocabulary flashcards covering the core concepts of the nursing process, clinical judgment, diagnostic formats, and care planning principles.

Critical Thinking

The ability to think in a systematic, logical way that focuses on making important decisions about clinical situations.

Clinical Judgment

A nurse's ability to assess situations, identify priorities, and determine what to do regarding client needs based on nursing knowledge, experience, evidence-based practices, and critical thinking.

Clinical Decision Making

The practice that separates the professional nurse from unlicensed assistive personnel, requiring the nurse to monitor clients, collect and analyze data, recognize problems, plan strategies, and take emergency action.

Nursing Process

A framework defined by the American Nurses Association (ANA) that nurses use to apply critical thinking in practice to diagnose and treat human responses to health problems.

Assessment

The first step of the nursing process, which involves collecting and verifying data from primary and secondary sources, followed by analyzing the data to make an accurate clinical judgment.

Dysuria

A feeling of pain when urinating.

Data Clusters

Sets of cues organized into patterns from collected assessment data that help nurses form diagnostic conclusions.

NANDA International (NANDA-I)

A professional organization that developed standardized patterns of data and precise definitions for nursing diagnoses.

Problem-Focused Nursing Diagnoses

Also called negative diagnoses, these identify an undesirable human response to an existing problem and consist of the problem, etiology, and defining characteristics.

Risk Nursing Diagnoses

Diagnoses used for clients who have an increased potential to develop a problem or complication they do not currently have; composed of a potential problem statement and risk factors.

Health Promotion Nursing Diagnoses

Also called positive diagnoses, these identify a client's desire or ability to improve health status through positive behavioral changes; composed of a diagnosis label and defining characteristics.

PES Format

The structural format used to write problem-focused nursing diagnoses, standing for Problem, Etiology, and Symptoms (or defining characteristics).

Etiology

The component of a nursing diagnosis describing the possible cause or reason for the problem, which guides nursing interventions and must not be a medical diagnosis or procedure.

Defining Characteristics

The clinical signs and symptoms that a client experiences and displays related to a nursing diagnosis.

Prioritizing

Ranking nursing diagnoses or client problems to establish a preferential order for interventions based on urgency, safety, client preferences, treatments, and other diagnoses.

Goal

A broad statement developed during planning that directly relates to the problem portion of the nursing diagnosis and describes the desired change.

Expected Outcomes

Measurable steps written in the SMART format to achieve a broader goal, each focusing on a single specific client behavior or response.

SMART Format

A framework for writing client expected outcomes requiring them to be Specific, Measurable, Attainable, Realistic, and Timed.

Implementation

The step in the nursing process where planned nursing interventions are executed and recorded in the medical record.

Evaluation

A continuous step in the nursing process where the nurse assesses client status and intervention effectiveness to determine whether outcomes were met or if the care plan requires modification.

SBAR

A structured communication tool standing for Situation, Background, Assessment, and Recommendation, used to share client information among healthcare team members.

Urinary Incontinence

The involuntary leakage of urine.