Nursing Process and Clinical Judgment Flashcards

A set of vocabulary flashcards reviewing clinical decision-making, the nursing process, delegation rules, and diagnosis types from the lecture.

Septaner

An antibiotic commonly prescribed to children that can cause orange-colored stool as an expected, non-emergency finding.

White Blood Cells (WBCs)

Fighter cells in the immune system that increase in count during an infection and decrease as antibiotic treatment improves the condition.

Nursing Diagnosis

A clinical judgment about a human response to a health condition or life process, such as acute pain, constipation, or decreased cardiac output.

Medical Diagnosis

The formal identification of a disease or physiological condition, such as appendicitis or gastroenteritis.

Standardized Language

Consistent, objective clinical terminology used in nursing care planning to ensure care quality, predictability, and effective communication across the healthcare team.

Rationale

The clinical reason or 'why' behind performing a specific nursing intervention or action.

Outcome

A patient-centered goal established during the planning phase that interventions are designed to directly impact.

SMART Outcome

A patient goal that is Specific, Measurable, Attainable, Realistic, and Timely.

Healthcare Provider (HCP)

The standardized term used by NCLEX and clinical exams to refer to authorized prescribers, such as physicians, Nurse Practitioners (NPs), and Physician Assistants (PAs).

Dependent Intervention

A nursing action that requires an authorized prescription or protocol from a Healthcare Provider (HCP) before execution, such as administering medication.

Closed Loop Communication

A communication strategy where the sender conveys a message and the receiver repeats back or verifies the details to ensure clear and accurate understanding.

Standing Order

A pre-approved provider order or protocol already in place that allows nurses to initiate specific interventions automatically when designated criteria are met.

Care Bundle

A standardized set of evidence-based interventions applied consistently to all patients under specific scenarios, such as Foley catheter care or surgical prep.

Direct Intervention

A nursing care action physically performed directly on or with the patient.

Indirect Intervention

A nursing care action performed away from the patient on their behalf, such as consulting interdisciplinary teams or delegating tasks.

Unlicensed Assistive Personnel (UAP)

Unlicensed healthcare workers, such as Certified Nursing Assistants (CNAs) or Patient Care Technicians (PCTs), who perform delegated nursing tasks.

E.A.T. Rule

A delegation principle stating that a Registered Nurse cannot delegate any task that requires them to Evaluate, Assess, or Teach.