Nursing Process, Critical Thinking, and Concept Maps Review

Flashcards covering the nursing process, data classification, nursing diagnosis standards, clinical judgment skills, NGN item types, and the structure of concept maps.

Nursing Process

A client-centered, five-step "Model of care" consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

RN (Registered Nurse)

The professional role responsible for initiating the nursing care plan.

LPN (Licensed Practical Nurse)

The professional role responsible for implementing the nursing care plan.

Nursing Process Characteristics

A set of traits including being systematic/structured, organized, problem-solving, scientific-based, and focused on managing illness.

Subjective Data

Information only perceived by the person experiencing it; it must be documented in the patient’s own words using quotation marks.

Objective Data

Measurable and observable information collected through physical exams, diagnostic tests, lab values, or medical records.

Physical Exam Techniques

The four specific methods used to collect objective data: Inspection, Palpation, Percussion, and Auscultation.

Assessment (Intervention Type)

Interventions that are either independent (nurse-initiated) or collaborative (requiring a provider order).

Evaluation

The step of the nursing process used to determine if goals were met and if the care plan requires modification.

Nursing Diagnosis

A clinical judgment about a client’s response to health problems that serves as the foundation of the care plan; it cannot use a medical diagnosis as the problem.

PES Format

The structure for an actual nursing diagnosis: Problem + Etiology + Signs/Symptoms.

Risk for Diagnosis

A potential nursing diagnosis where the "as evidenced by" (Signs/Symptoms) portion is omitted because the event hasn't happened yet.

NANDA

The North American Nursing Diagnosis Association, the organization that approves the official list of nursing diagnoses.

Etiology Categories

The four types of causes for nursing diagnoses: Situational, Physiological, Treatment-related, and Psychological.

Clinical Judgment

A decision-making process using nursing knowledge to observe situations, identify prioritized concerns, and generate evidence-based solutions.

Dichotomous Scoring

An NCLEX scoring method where an answer is only right or wrong, resulting in either $0$ or $1$ point.

Polytomous Scoring

An NGN scoring method that allows for partial credit, such as $0$, $1$, $2$, or $3$ points.

Cloze (Drop-Down)

A Next Generation NCLEX (NGN) item type that requires using a drop-down list to complete a sentence.

Interpretation

A critical thinking tool defined as clarifying the meaning of data or events.

Analysis

A critical thinking tool defined as breaking ideas into components.

Self-Regulation

A critical thinking tool defined as reconsidering one’s own thinking.

Concept Map

A visual tool used to simplify and organize client data that mirrors how the brain naturally stores and links information.

Concept Map Center

The location where the admitting medical diagnosis (e.g., Pneumonia) is placed when building a map.