The Nursing Process and Interpersonal Skills

Flashcards covering key terms and concepts related to the nursing process and interpersonal skills.

Assessment

The process of collecting, organizing, validating, and recording data about a client’s health status.

Nursing Diagnosis

The nurse’s clinical judgment about individual, family, or community responses to actual and potential health problems.

Planning

An ongoing process that involves assessing a situation, establishing goals and objectives, and developing a plan of action.

Implementation

The phase of the nursing process in which the nursing care plan is put into action.

Evaluation

A planned ongoing activity in which patients and health care professionals compare expected outcomes to actual outcomes.

Documentation

The process of making an entry on a client record.

Interpersonal Skills

All the activities, verbal and non-verbal, people use when interacting directly with one another.

Subjective Data

Symptoms apparent only to the person affected and can be described or verified only by that person.

Objective Data

Signs detectable by an observer or measurable against an accepted standard.

Primary Data

The patient is the primary source of data.

Secondary Data

All sources other than the patient that provide information.

Types of Assessment

Initial, problem-focused, emergency, and time-lapsed assessments.

Initial Assessment

To establish a complete database for problem identification.

Problem-Focused Assessment

To determine the status of a specific problem identified in an earlier assessment.

Emergency Assessment

To identify life-threatening problems or new problems.

Time-Lapsed Assessment

To compare the patient’s status to baseline data previously obtained.

Nursing Care Plan

A plan that specifies the nursing care for a patient.

Setting Priorities

The process of establishing a preferential sequence for addressing nursing diagnoses.

Short-Term Goals

Goals that can be achieved in a short period of time.

Long-Term Goals

Goals that can take a longer period of time to achieve.

Cognitive Skills

Include problem solving, decision making, critical thinking, and clinical reasoning.

Technical Skills

Purposeful hands-on skills such as manipulating equipment and administering medications.

Communication

A two-way process involving the sending and receiving of messages.

Feedback

The response from the receiver which allows the sender to correct or reword a message.

Congruence

The match between verbal and non-verbal aspects of communication.

Barriers to Communication

Obstacles that prevent effective exchange of information.

Non-Verbal Communication

Uses other forms of communication like gestures, facial expressions, and body language.

Verbal Communication

Uses spoken or written words to convey messages.

Therapeutic Communication

A communication process designed to encourage the client to express feelings.

Decision Making

The process of making choices by identifying a decision, gathering information, and assessing alternative resolutions.

Problem Solving

A systematic approach to finding solutions to difficult or complex issues.

Critical Thinking

The objective analysis and evaluation of an issue in order to form a judgment.

Characteristics of Nursing Process

Cyclic, patient centered, problem solving, and decision making in every phase.

Cyclic Nature

Each phase gives input for the next phase in the nursing process.

Documentation Importance

Legal protection and effective communication among health care professionals.

Interpersonal Attitudes

Beliefs, thoughts, and feelings conveyed through communication.

Privacy

The right of individuals to control access to personal information.

Ethical Considerations

Maintaining confidentiality and privacy of patient information.

Nursing Interventions

Actions performed by nurses to achieve client goals.

Discharge Planning

The process of anticipating and planning for needs after discharge.

Patient-Centered Care

An approach that focuses on the patient’s preferences, needs, and values.

Nurse-Patient Relationship

A professional bond that guides interactions between nurse and patient.

Documentation Systems

Structured methods for recording patient information, including source-oriented and problem-oriented records.

Change-of-Shift Report

A process for communicating patient care information between shifts.

Case Management

A care delivery model that focuses on coordination of services and improved outcomes.