Introduction to the Nursing Process and Assessment

These flashcards cover the fundamental concepts of the nursing process (ADPIE), types of assessment data, physical examination techniques, and goal-setting criteria as described in Chapters 5 and 6 of the Fundamentals textbook.

What is the nursing process?

The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients.

What are the five primary steps of the nursing process?

Assessment, diagnosis, planning, implementation, and evaluation, often referred to by the acronym ADPIE.

Which nurse first used the term "nursing process" in 1955?

Lydia Hall

Why is the nursing process described as dynamic?

It changes over time in response to patients' needs, allowing nurses to modify the plan of care as the patient's condition evolves.

What is the difference between primary and secondary data in nursing assessment?

Primary data consist of information obtained directly from the patient, while secondary data are collected from family, friends, other health care professionals, or written sources like medical records.

How are subjective and objective data distinguished?

Subjective data (symptoms) are spoken feelings or comments shared verbally by the patient; objective data (signs) consist of observable information that can be seen, measured, or tested.

In what order are the four physical assessment techniques performed for most body systems?

Inspection, palpation, percussion, and auscultation.

Why does the sequence of abdominal assessment change to auscultation before palpation and percussion?

To avoid stimulating the bowel before listening to bowel sounds.

What is a nursing diagnosis according to the American Nurses Association (ANA)?

The nurse's clinical judgment about a client's response to actual or potential health conditions or needs.

What is the difference between a medical diagnosis and a nursing diagnosis?

Medical diagnoses are labels for diseases, whereas nursing diagnoses consider a patient's response to medical or mental health diagnoses and life situations.

What are the three essential criteria for all short-term and long-term goals?

They must be (1) patient or group focused, (2) realistic, and (3) measurable.

What is the typical timeframe for a short-term goal?

Achievable within an immediate time frame of less than approximately $1$ week.

Define "collaborative care" in the context of nursing.

Coordinated, team-based patient care involving the patient's health care team members, such as nurses, primary care providers, therapists, and social workers.

What are protocols in the implementation phase?

Written plans that can be generalized to groups of patients with similar clinical needs that do not require a physician's order.

What are standing orders?

Orders written by physicians listing specific actions to be taken by a nurse when a physician is not accessible or when care is common to a certain situation, such as chest pain.

In the evaluation step, what does the nurse decide regarding the plan of care?

Whether the plan of care should be discontinued, continued, or revised based on whether goals and outcomes were met.

What is the Emergency Severity Index (ESI)?

A five-tier triage system that classifies patients by level numbered $1$ through $5$ based on the urgency of their condition.

What is a "cue" in data validation?

A hint or an indication of a potential disease process or concern, such as a patient wincing which may indicate pain.

What is the focus of Gordon's Functional Health Patterns?

It is a holistic approach that organizes data based on areas of function, such as health perception, nutrition, and activity, to help nurses focus on patient strengths and data relationships.

Which tasks regarding assessment cannot be delegated to unlicensed assistive personnel (UAP)?

Initial and ongoing assessment of patients requiring critical care cannot be delegated to UAP.