Nursing Process:Foundations Introduction to Patient Care and Critical Thinking

A set of 40 vocabulary-style flashcards covering the foundations of nursing, including person-centered practice, the nursing process, clinical reasoning, and professional competencies.

Person-Centered Practice

A practice model where all team members are caregivers, care is based on continuous healing relationships, and the patient is the source of control for their care.

Reflective Practice

A process leading to personal learning where the nurse utilizes personal attributes, a knowledge base, and clinical experience to improve care.

Blended Competencies

The set of cognitive, technical, interpersonal, and ethical or legal competencies required for professional nursing.

QSEN Competencies

Quality and Safety Education for Nurses competencies integrated into the patient-centered nursing process to ensure safety and transparency.

Assessing

The systematic and continuous collection, analysis, validation, and communication of patient data.

Diagnosing

The process of interpreting and analyzing patient data to identify patient strengths and health problems, formulating a prioritized list of health issues.

Planning

Developing an individualized plan of care that specifies desired patient goals, related outcomes, and nursing interventions.

Implementing

The step of the nursing process where the nurse executes the plan of care.

Evaluating

Measuring the effectiveness of the plan of care in terms of patient goal achievement and identifying factors contributing to success or failure.

Clinical Reasoning

The process used to think about patient problems in the clinical setting, involving analyzing a situation, making a judgment, and deciding on actions.

Clinical Judgment

The result or outcome of critical thinking, clinical reasoning, and decision making.

Cognitive Competencies

Critical thinking skills that involve identifying the purpose of thinking, adequacy of knowledge, potential problems, and helpful resources.

Technical Competencies

The development of manual skills and use of equipment necessary for patient care.

Interpersonal Competencies

Skills focused on promoting human dignity and respect, establishing caring relationships, and mutual exchange.

Ethical/Legal Competencies

An understanding of legal boundaries, scope of practice, and personal responsibility and strengths.

Trial-and-error Problem Solving

A method that involves testing solutions until one is found that works for a specific situation.

Scientific Problem Solving

A systematic, $7$-step process for identifying and resolving clinical problems.

Intuitive Problem Solving

A direct understanding of a situation based on a background of experience, knowledge, and skill that enables expert decision making.

Noticing

In the Tanner Model, the perceptual grasp of the situation at hand.

Interpreting

In the Tanner Model, developing a sufficient understanding of the situation to respond.

Responding

In the Tanner Model, deciding on a course of action deemed appropriate for the situation.

Reflecting

In the Tanner Model, attending to patients’ responses to nursing actions while in the process of acting.

Nursing Process

A six-part systematic method (assessing, diagnosing, outcome identification, planning, implementing, and evaluating) to provide scientifically based, holistic care.

Database

The collection of all pertinent patient information gathered by the nurse and other health care professionals to enable effective care planning.

Initial Assessment

A type of assessment performed shortly after the patient is admitted to the healthcare facility.

Focused Assessment

An assessment conducted to gather data about a specific problem that has already been identified.

Emergency Assessment

A rapid assessment performed when a physiologic or psychological crisis occurs to identify life-threatening problems.

Time-lapsed Assessment

An assessment used to compare a patient's current status to baseline data obtained earlier.

Cue

Subjective or objective data that are identified by the nurse as significant for making clinical judgments.

Inference

The judgment or interpretation reached about the cues identified during data collection.

HIPAA

The Health Insurance Portability and Accountability Act, which establishes ethical responsibilities for safeguarding the privacy of patients.

NANDA International

An organization that provides a beginning list of suggested terms for health problems used for formulating nursing diagnoses.

Problem-focused Nursing Diagnosis

A clinical judgment concerning an undesirable human response to a health condition or life process.

Risk Nursing Diagnosis

A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response.

Health Promotion Nursing Diagnosis

A clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.

Etiology

The part of the nursing diagnosis that identifies the factor that maintains the unhealthy condition or the cause of the problem.

Patient-centered Measurable Outcomes

Specific goals that include a subject, a measurable verb, conditions, performance criteria, and a target time.

Nurse-initiated Interventions

Actions performed by a nurse to monitor health status, reduce risks, or promote independence without a physician's order.

Nursing: Scope and Standards of Practice

A document by the ANA that describes the "who," "what," "where," "when," "why," and "how" of professional nursing practice.

Evaluative Statement

A written judgment that includes the decision on how well an outcome was met (met, partially met, or not met) and supporting patient data.