Nursing Process and Assessment Vocabulary Flashcards

Vocabulary flashcards covering the nursing process, priority setting, assessment types, data classification, and therapeutic communication phases from the lecture.

Nursing Process

A standardized, methodical framework followed by nurses to care for patients that is constantly evolving based on continuous assessment.

Clinical Judgment

How a nurse thinks and acts when evaluating, treating, and taking care of patients in a clinical setting.

Priority Setting Rule

The principle of always prioritizing clinical care and interventions based on what will kill the patient first.

Evidence-Based Practice

Interventions and rules established through research, experimentation, and published scientific evidence to determine standard best practices.

Objective Data

Measurable and observable information gathered through assessment, such as vital signs, temperature, wound size, or visible vomiting.

Subjective Data

Information reported directly by the patient or family about feelings and symptoms, such as pain ratings or nausea, which cannot be directly measured.

Baseline

An initial clinical measurement taken at admission or pre-op used as a reference point to track changes and trends in a patient's condition over time.

Initial Comprehensive Assessment

An extensive admission history gathering complete background information on a patient, including medical history, mobility, religious beliefs, and diet preferences.

Problem-Focused Assessment

A targeted clinical examination focused specifically on a particular concern, recent change, or previously identified health problem.

Emergent Assessment

A rapid priority evaluation conducted during life-threatening situations to stabilize immediate critical conditions.

ABCs

An acronym standing for Airway, Breathing, and Circulation, which represents the essential priority sequence in critical patient care.

Primary Source

The actual patient as the direct provider of health information.

Secondary Source

Any source of health information other than the patient, including family members, medical records, diagnostics, or other healthcare team members.

Post-operative

The period of time immediately following a surgical procedure.

Orientation Phase

The initial stage of nurse-patient interaction where the nurse introduces their role, protects privacy, establishes rapport, and identifies patient priorities.

Working Phase

The stage of communication where the nurse explores the health story using open-ended questions, attentive listening, clarification, and targeted inquiry.

Termination Phase

The concluding stage of communication where the nurse summarizes gathered information, explains the care plan and next steps, and invites final patient questions.

Open-ended Questions

Communication prompts designed to allow patients to elaborate, share backstory, and provide detailed health information rather than limited single-word answers.