The Nursing Process: Critical Thinking, Decision Making, and Clinical Judgment

Vocabulary flashcards covering the five steps of the nursing process, critical thinking concepts, assessment types, and professional nursing standards.

Care Plan

A documented plan for giving patient care that includes the health-care provider's orders, nursing diagnoses, and nursing orders.

Critical Thinking

Using skillful reasoning and logical thought to determine the merits of a belief or action.

Validate

To ensure the correctness of the information obtained about patients and their care.

Nursing Process

A decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.

ADPIE

A mnemonic used to remember the five steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The gathering of information through signs and symptoms, patient history, and both subjective and objective findings using interviewing, focused physical examinations, and reviewing diagnostic tests.

Nursing Diagnosis

The formulation of patient needs or problems derived from an analysis of assessment data, selected based on definitions and defining characteristics.

Planning

The process of determining priorities, setting expected outcomes within a realistic time frame, and deciding on appropriate nursing actions (interventions) to resolve or manage patient problems.

Implementation

The process of taking actions (performing nursing interventions) to resolve the patient's problems.

Evaluation

The step in which the nurse reflects on the interventions performed and decides whether the patient is closer to achieving the goals and outcomes, revising interventions or goals as needed.

American Nurses Association (ANA) Standards of Practice

Standards establishing that all steps of the nursing process, from assessment through evaluation (including outcome identification), are the legal responsibility of the registered nurse (RN).

National Federation of Licensed Practical Nurses (NFLPN) Nursing Practice Standards

Standards identifying assessment and nursing diagnosis as the responsibilities of the RN, while the LPN/LVN participates directly in planning, intervention, and evaluation.

Objective Data

Information that can be directly observed and detected through the senses of sight, hearing, smell, and touch without drawing inferences or conclusions.

Subjective Data

Information that is known only to the patient and family members—such as pain, nausea, anxiety, or fear—which must be attributed directly to the patient.

Rapport

A relationship of mutual trust and understanding created between the nurse and patient before and during the nursing interview.

Medical Diagnosis

The disease or illness diagnosed by the physician (such as appendicitis, pneumonia, or thrombophlebitis) that describes a physical condition.

Primary Data

Assessment information provided directly by the patient.

Secondary Data

Assessment information obtained from family members, friends, or the patient's chart.

Inspection

The visual examination of the patient's body for rashes, breaks in the skin, and normal appearance of the eyes, ears, nose, mouth, limbs, and genitals.

Palpation

The physical examination technique of touching or feeling the torso and limbs for pulses, abnormal lumps, temperature, moisture, and vibrations.