Nursing Process and Assessment

These flashcards cover key terms and concepts from the lecture notes on nursing processes, assessments, and communication techniques.

ADPIE

The nursing process sequence that includes Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Actual Diagnosis (Dx)

A problem statement that includes the problem, etiology, and evidence, known as PES.

Risk Diagnosis (Dx)

A problem statement that includes the problem and risk factors, but no evidence yet.

Therapeutic Techniques

Communication methods used to build trust, including open-ended questions, reflection, and clarification.

COLDSPA

An acronym used in health history to assess the characteristics of pain (Character, Onset, Location, Duration, Severity, Pattern, Associated factors).

Validation

The process of checking and confirming data before making a diagnosis.

Subjective vs Objective Findings

Subjective findings are reported by the patient; objective findings are observed by the healthcare provider.

FACT Documentation

A rule for charting that stands for Factual, Accurate, Complete, Timely.

Nutritional Assessment

Evaluation of a patient’s dietary intake through ABCD: Anthropometric, Biochemical, Clinical, and Dietary assessment.

ABCDE Rule for Skin Cancer

A guideline for identifying melanoma: Asymmetry, Border, Color, Diameter greater than 6 mm, and Evolution.

Pain Assessment

The evaluation of pain which is subjective and should be assessed each time vital signs are taken.

SMART outcomes

Specific, Measurable, Achievable, Relevant, Time-bound outcomes that are established during the planning phase.

CAGE Questionnaire

A tool used to assess potential alcohol dependence, where a score of 2 or more indicates possible dependence.

Erikson Stages of Development

Developmental framework that includes tasks at each life stage, such as Trust vs Mistrust in infants.

Mini-Mental State Exam (MMSE)

A quick screening tool for cognitive impairment, where a score of 24 or higher is considered normal.