The Nursing Process

Flashcards covering key vocabulary and concepts from a Nursing Process lecture, focusing on ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation).

Nursing Process

A systematic and science-based approach that utilizes critical thinking and is goal-oriented. It is non-linear, dynamic, and continuous and creates a standard of practice.

Assessment

Gather subjective and objective information about the patient.

Diagnosis

Identify the patient's problem(s).

Planning

Create a plan of action (SMART goals) to address the patient's diagnosis.

Implementation

Apply the plan of action.

Evaluation

Determine if the plan of action met the patient's goals. If not, reassess and start over.

Patient-Centered Interview

Comprehensive or focused; sources include the patient, family, healthcare team, and records.

Periodic Assessment

Conducted during ongoing care with the patient; typically focused (e.g., ABCDE/quick screenings).

Physical Exam

Conducted during history & at time of symptoms; can be comprehensive or focused.

Subjective Data

Self-report, History.

Objective Data

Exam, Diagnostics.

Components of Health History

Biographical/Demographic Information, Reason for seeking care/Admitting Diagnosis, History of Present Illness (COLDSPA), Family History, Review of Systems, Environmental history, Psychosocial & Spiritual History.

Objective Data Collection

Temp, HR, RR, BP, O2, Height/Weight, Patient’s Behavior, Inspect, Palpate, Percuss, Auscultate, Imaging, Laboratory, Risk Assessments, Falls, Pressure Ulcers, DVT

Medical Diagnosis

Given by a physician or advanced practice provider; a name given to describe a disease or condition (e.g., Diabetes, Asthma, Heart Failure).

Nursing Diagnosis

Used exclusively by nurses; describes a patient’s response or vulnerability to a health condition.

Collaborative Problem

Requires both medical and nursing interventions to treat a specific problem (e.g., infected leg).

Actual Nursing Diagnosis

Sufficient data to establish a problem.

Risk Nursing Diagnosis

Environmental, physiological, psychological, genetic, or chemical risk factors.

Health Promotion Nursing Diagnosis

Can be used in any health state.

Problem Statement

Patient’s response to a condition; a NANDA approved statement.

Etiology (R/T)

Cause of the problem; pathophysiology, treatment, situational (NOT medical diagnosis).

Defining Characteristics

Evidence of the problem; signs & symptoms (AEB).

Prioritizing

Ranking patient’s problem(s) in order of importance; consider Maslow’s Hierarchy of Needs (Airway, Breathing, Circulation, Discomfort).

Goals & Outcomes

Patient-Centered, Short Term & Long Term, SMART (Specific, Measurable, Attainable, Relevant, Time-Bound).

Interventions

Patient-Centered to achieve goals, Evidence Based, Independent (Nursing initiated), Dependent (Provider initiated), Collaborative.

Physiological Needs

Oxygen, nutrition, fluids, body temp, elimination, shelter, sex.

Safety & Security Needs

Physical safety, psychological safety.

Love & Belonging Needs

Family & friends.

Self-Esteem Needs

Encourage daily activities & personal care.

Self-Actualization Needs

Mitigate discouragement, encourage daily, help maintain positive attitude, help accept new identity.

Direct Interventions

Safety, Fall precautions.

Indirect Interventions

Medication Administration, VS.

Implementation Process

Re-assess patient (if needed), Review/Revise Plan of Care, Organize Resources & Care Delivery, Anticipate & Prevent Complications.

Evaluation

Ongoing; final step of the nursing process that determines whether a patient’s condition or well-being improved after nursing interventions were delivered.

Interventions (Evaluation)

Were the nursing interventions appropriate? Were the nursing interventions effective or not?

Goals (Evaluation)

Were the goals met? Yes? Problem solved! No? Why? Revise!