The Nursing Process and Clinical Judgement

Vocabulary flashcards covering key terms from the Nursing Process, assessments, diagnosis, planning, implementation, and evaluation, including related models, methods, and quality frameworks.

Nursing Process

A systematic, patient-centered framework guiding nursing care through Assessing, Diagnosing, Planning, Implementing, and Evaluating (ADPIE).

ADPIE

The five steps of the nursing process: Assessing, Diagnosing, Planning, Implementing, Evaluating.

Assessing

Systematic collection of patient data to establish a baseline and identify health problems.

Diagnosing

Interpreting data to identify actual or potential health problems and formulate nursing diagnoses.

Planning

Developing individualized care plans with defined outcomes and nursing interventions.

Implementing

Carrying out the plan of care and performing nursing interventions.

Evaluating

Judging whether the patient has achieved the expected outcomes and modifying the plan as needed.

Objective Data

Observable, measurable data (e.g., vital signs, lab results) that can be seen or measured by others.

Subjective Data

Data perceived only by the patient (e.g., pain, dizziness, feelings).

Data Validation

Process of confirming the accuracy and reliability of data collected.

Data Clustering

Grouping related cues to identify patterns or problems.

Primary Source

The patient themselves is the main source of data.

Secondary Source

Data obtained from sources other than the patient, such as family, records, or clinicians.

Sources of Data

Various channels for data collection, including patient, family, medical records, labs, and reports.

Assessment Methods (IPPA)

Inspection, Palpation, Percussion, Auscultation used to collect data.

Initial Assessment

Performed soon after admission to establish a complete database for problem identification and planning.

Focused Assessment

Data collection targeted to a specific problem or condition already identified.

Quick Priority Assessment

Short, focused, prioritized assessment to obtain essential information quickly.

Emergency Assessment

Assessment performed during a physiologic or psychological crisis to identify life-threatening problems.

Time-Lapsed Assessment

Reassessment comparing current status to baseline data obtained earlier.

Triage Assessment

Screening assessment to determine problem extent/severity and follow-up needs.

Patient-Centered Assessment Method (PCAM)

Tool to assess patient complexity using social determinants of health.

Assessment Priorities

Determining which patient data and problems require attention first based on risk and impact.

Maslow’s Hierarchy of Needs

Framework prioritizing physiological, safety, love/belonging, esteem, and self-actualization needs.

Patient Preference

Nurse considers the patient’s values and choices when planning care.

Developmental Stage

Stage of growth (e.g., infant, child) used to tailor assessment and care planning.

Clinical Reasoning

Thoughtful, evidence-based process of analyzing data to make nursing decisions.

Critical Thinking

Systematic, reflective thinking to evaluate data and reach justified conclusions.

Clinical Judgment

Decision and action based on data, reasoning, and experience to address patient needs.

Tanner Model

Noticing, Interpreting, Responding, Reflecting—stages of clinical judgment.

Lasater Clinical Judgment Rubric

Tool to assess nursing students’ clinical judgment across Noticing, Interpreting, Responding, Reflecting.

CJMM / CJAM

NCSBN Clinical Judgment Measurement Model and its action model; layers describe how clinical judgment informs decisions.

NOC

Nursing Outcomes Classification; standardized outcomes used to describe patient outcomes.

NIC

Nursing Interventions Classification; standardized interventions nurses perform.

Nursing Diagnosis

A clinical judgment about unhealthy responses to health problems that nursing can address, not a medical diagnosis.

Medical Diagnosis

A diagnosis of disease or pathology directing medical treatment; not the focus of nursing diagnoses.

NANDA-I

North American Nursing Diagnosis Association International; standard taxonomy for nursing diagnoses.

Problem-Focused Diagnosis

A nursing diagnosis based on existing problems with defining characteristics.

Risk Diagnosis

A nursing diagnosis describing vulnerability to a health problem.

Health Promotion Diagnosis

A nursing diagnosis focused on readiness to enhance well-being.

Related To (rt)

Etiology linking the nursing problem to contributing factors in a diagnostic statement.

As Evidenced By (AEB)

Defining characteristics or cues that support the nursing diagnosis.

Writing Nursing Diagnoses

Crafting statements that reflect patient responses, avoid illness signs as problems, and remain legally safe.

Outcomes

Expected patient responses or results used to evaluate care effectiveness.

Outcome Identification

Process of specifying expected patient outcomes tied to the nursing diagnoses.

SMART Goals

Specific, Measurable, Achievable, Relevant, Time-bound goals used to guide outcomes.

Five Rights of Delegation

Right Task, Right Circumstance, Right Person, Right Directions and Communication, Right Supervision and Evaluation.

Protocol

A written plan detailing nursing activities for a specific situation; may be less flexible.

Standing Orders

Preapproved orders allowing nurses to initiate actions without direct provider approval.

Order Set

Preprinted provider orders to standardize care after a validated practice standard.

Care Bundle

A small set of evidence-based practices that improve outcomes when performed together.

Guideline

Broad, research-based recommendations for practice, not always tested in practice.

Algorithm

A binary decision-tree guide for stepwise assessment and intervention with high specificity.

Critical Pathway

An interdisciplinary, minimal-practice standard for a specific patient population.

Evidence-Based Practice

Integration of the best available research with patient values and clinical expertise.

Alfaro’s Rule

Assessment, reassessment, revision, and recording of patient status after interventions.

Evaluative Statements

Statements describing whether outcomes were met, partially met, or not met and supporting data.

IOM Six Aims

Quality aims: Safe, Effective, Patient-centered, Timely, Efficient, Equitable.

Joint Commission NP Safety Goals

Goals to ensure correct patient identification, effective communication, safe medication use, infection prevention, and safety risk identification.