CHAPTER 4: The Nursing Process, Critical Thinking, Decision Making & Clinical Judgment

Vocabulary flashcards covering the Nursing Process (ADPIE), critical thinking, clinical judgment, data types, assessment techniques, and types of nursing interventions.

Nursing Process

The ADPIE framework for nursing care consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment (A)

The first step of ADPIE involving collecting information about the patient via interviewing, physical assessment, and lab/diagnostic review.

Diagnosis (D)

Analyzing assessment data to identify patient problems nurses can treat; it is not the same as a medical diagnosis.

Planning (P)

Creating goals, outcomes, interventions, and priorities to determine what nurses will do to help the patient improve.

Implementation (I)

The step where nursing interventions are performed, such as giving medications, oxygen therapy, repositioning, or wound care.

Evaluation (E)

Determining if goals/outcomes were met, if interventions worked, and if the care plan needs to be changed.

Critical Thinking

The use of logic and reasoning to avoid assumptions, validate information, and make safe decisions.

Validation

The process of double-checking information for accuracy before assuming it is correct.

Clinical Judgment

The process of turning critical thinking into nursing action by recognizing and analyzing cues, prioritizing actions, and evaluating response.

Subjective Data

Information that the patient reports feeling or says, such as pain, nausea, or anxiety; remembered as "Symptoms said."

Objective Data

Information that the nurse can observe or measure, such as blood pressure, fever, or a rash; remembered as "Observable."

Primary Data

Information obtained directly from the patient.

Secondary Data

Information obtained from sources other than the patient, such as family, medical charts, or other staff.

Inspection

A physical assessment technique that involves looking at signs like skin color, swelling, or wounds.

Palpation

A physical assessment technique that involves touching or feeling for pulses, temperature, or edema.

Auscultation

A physical assessment technique that involves listening to sounds such as lung, bowel, or heart sounds.

Percussion

A physical assessment technique that involves tapping the body to detect fluid or air.

Rapport

A trust relationship built between the nurse and patient through introduction, eye contact, and listening.

Maslow’s Hierarchy

A system used by nurses to prioritize needs from lowest to highest: physiological, safety, love/belonging, self-esteem, and self-actualization.

Physiological Needs

The highest priority needs in Maslow's Hierarchy, including oxygen, breathing, circulation, food, water, and pain relief.

ABCs

An NCLEX priority framework standing for Airway, Breathing, and Circulation.

NANDA-I

A standardized nursing diagnosis system used to create approved nursing diagnoses.

PES Statement

A three-part nursing diagnosis consisting of the Problem (Diagnosis), Etiology (Cause/"related to"), and Symptoms (Evidence/"as evidenced by").

Nursing Goal

A broad desired improvement for the patient, such as improving mobility.

Expected Outcome

A specific, measurable patient result that must be realistic, patient-centered, and time-limited.

Independent Interventions

Actions a nurse can take without a provider order, such as repositioning, oral care, or patient teaching.

Dependent Interventions

Actions that require a provider order, such as administering medications, IV therapy, or enemas.

Collaborative Interventions

Interventions performed with the healthcare team, including respiratory therapy, dietitians, or physical therapy.

Direct Care

Hands-on patient care such as bathing, medication administration, and dressing changes.

Indirect Care

Helping the patient away from the bedside, such as charting, calling providers, or care conferences.

Care Plan

A written guide organizing patient care that must be individualized for each patient.

Critical Pathways

Standardized care plans that outline the expected daily progress of a patient.