Module 3 Nursing Process: Diagnosis, Planning, Implementation, and Evaluation

Vocabulary flashcards defining core terms related to nursing diagnosis, care planning, intervention classification, delegation, and evaluation based on the lecture notes.

Nursing Diagnosis (Patient Problem Statement)

The patient's clinical response to actual or potential health problems (e.g., acute pain, anxiety) which can change as the patient's condition evolves.

Medical Diagnosis

A specific disease or condition diagnosed and treated by a physician (e.g., pneumonia, diabetes) that generally remains consistent as long as the disease is present.

Etiology

The cause or contributing factors of a patient's health problem, which direct the choice of appropriate nursing interventions.

Problem-Focused Nursing Diagnosis

A NANDA nursing diagnosis for an existing undesirable human response, requiring both related factors (etiology) and defining characteristics (signs and symptoms/evidence).

Risk Nursing Diagnosis

A NANDA nursing diagnosis indicating a vulnerability to a health problem that does not yet exist, requiring only identified risk factors.

Health Promotion Nursing Diagnosis

A NANDA nursing diagnosis indicating a patient's readiness to enhance a specific health behavior or overall state of well-being.

PES Format

A three-part structured format for writing problem-focused nursing diagnoses consisting of Problem, Etiology (cause), and Signs/Symptoms (evidence).

SMART Format

A framework used to write effective patient outcomes/goals that are Specific, Measurable, Attainable, Realistic, and Timely.

Cognitive Outcomes

Patient outcome goals focused on increasing knowledge and understanding, evaluated by having the patient verbalize, list, or explain information.

Psychomotor Outcomes

Patient outcome goals centered on the acquisition of physical skills, evaluated by observing the patient's return demonstration of a procedure or action.

Affective Outcomes

Patient outcome goals addressing changes in values, beliefs, attitudes, or emotional responses, evaluated through observed behaviors and expressed feelings.

Nurse-Initiated Intervention

Autonomous nursing actions derived from scientific rationale tied to a diagnosis that do not require a physician's order (e.g., repositioning, fall prevention).

Physician-Initiated Intervention

Nursing actions ordered by a physician or healthcare provider in response to a medical diagnosis that are carried out safely by the nurse (e.g., administering prescribed medications).

Collaborative Intervention

Therapeutic activities initiated by other interprofessional healthcare providers (such as physical therapists or dietitians) that are coordinated and carried out by the nurse.

Standing Orders

Pre-approved protocols or orders that authorize nurses to perform immediate specific actions or administer treatments under defined clinical conditions without calling a doctor first.

Care Bundles

A standardized group of evidence-based interventions applied together for specific medical conditions to ensure consistent quality of care (e.g., ventilator care bundles).

Evaluative Statement

A formal documentation note composed of a judgment (met, partially met, or not met) accompanied by specific objective/subjective patient data as supporting evidence.

Five Rights of Delegation

The clinical standard guiding safe delegation decisions: right task, right circumstances, right person, right direction/communication, and right supervision/evaluation.