Nursing Process Lecture - NUR 155/156

Comprehensive vocabulary flashcards covering the five steps of the nursing process (ADPIE), assessment techniques, and types of nursing interventions as presented in the NUR 155/156 Unit 1 lecture.

Nursing Process

The foundation of professional nursing practice and the framework within which nurses provide organized and effective care requiring critical thinking.

ADPIE

The acronym representing the steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The organized and ongoing appraisal of a client’s well-being using a holistic approach to collect data.

Primary data

Information obtained directly from the client.

Secondary data

Information shared by family members, friends, or other members of the health care team.

Subjective data

Symptoms or spoken information provided by the client that are difficult to validate.

Objective data

Signs that can be measured or observed, such as physical examination findings, laboratory results, and diagnostic test results.

Inspection

A physical assessment technique that uses vision, hearing, and smell to closely scrutinize physical characteristics.

Palpation

A physical assessment technique using touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.

Percussion

Tapping the client’s skin with short, sharp strokes to cause a vibration that travels through the skin to underlying structures.

Auscultation

Listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, lungs, and abdominal cavity.

Nursing diagnosis

The analysis and clustering of related assessment information to identify a problem, potential problem, or opportunity for improvement.

Diagnosis label

A concise term or phrase in a NANDA-I nursing diagnostic statement that represents a pattern of related, clustered data.

Related factors

The underlying cause or etiology component of a NANDA-I nursing diagnostic statement.

Defining characteristics

Environmental, physical, psychological, or situational concerns within a NANDA-I nursing diagnostic statement.

Planning

The step where the nurse prioritizes hypotheses, establishes goals, chooses outcome indicators, and identifies interventions.

Short-term goal (STG)

An aim of nursing care that is achievable in less than 1 week.

Long-term goal (LTG)

An aim of nursing care that requires weeks or months to achieve.

Physiologic Needs

The most basic level of Maslow’s Hierarchy, including oxygen, water, food, elimination, temperature control, sex, movement, rest, and comfort.

Self-Actualization

The highest level of Maslow’s Hierarchy, involving recognition and realization of one's potential, growth, health, and autonomy.

Implementation

The initiation of appropriate actions and interventions designed to meet the unique needs of each client or group.

Independent nursing interventions

Tasks within the nursing scope of practice that a nurse may initiate without a physician or primary care provider (PCP) order.

Dependent nursing interventions

Tasks within the nursing scope of practice that require the order of a primary care provider (PCP) to be implemented.

Collaborative Interventions

Actions that require cooperation and coordination among various health care professionals and unlicensed assistive personnel (UAP).

Direct Care

Interventions carried out by having personal contact with the client, such as activities of daily living, physical care, and teaching.

Indirect Care

Interventions performed to benefit clients without face-to-face contact, such as advocacy, delegation, and referrals.

Evaluation

The final step of the nursing process which focuses on the client’s response to interventions and whether goals or outcomes were attained.