Nursing Process Overview and Steps

A series of flashcards designed to help nursing students review and understand the nursing process and related concepts.

Nursing Process

A systematic method used by nurses to ensure the effective and efficient delivery of care to clients.

Assessing

The first step of the nursing process; it involves gathering relevant information about the client through health history and physical examination.

Analyzing

The second step of the nursing process; it involves examining the data obtained to identify significant patterns and problems.

Nursing Diagnosis

A two-part statement that describes a client’s actual or potential responses to stressors related to contributing factors.

Planning

The third step of the nursing process; it involves setting goals and determining the nursing actions needed to achieve those goals.

Implementing

The fourth step of the nursing process; it involves carrying out the nursing interventions outlined in the care plan.

Evaluating

The fifth step of the nursing process; it refers to determining the effectiveness of nursing care by assessing if expected outcomes were achieved.

Expected Outcomes

Measurable changes in client behavior that indicate the effectiveness of nursing interventions.

Reassessment

The ongoing process of reviewing and updating the client’s data and condition.

Primary Prevention

Interventions aimed at preventing disease or injury from occurring.

Secondary Prevention

Activities aimed at early detection and treatment of disease to prevent worsening.

Tertiary Prevention

Actions focused on minimizing the impact of ongoing illness or injury.

Data Base

The collective information gathered about the client, including health history and physical assessment findings.

Physiological Assessment

A detailed evaluation of physical health; includes measuring vital signs and examining body systems.

Psychosocial Assessment

Evaluation of the client's psychological and social well-being.

Cultural Considerations

Factors related to the client's cultural background that may affect health and health care.

Client History

Information obtained from the client regarding their health status and reactions to their environment.

Nursing Orders

Specific instructions outlining the nursing actions to be taken for client care.

Problem Solving Process

A method involving steps to achieve a solution to a particular challenge; applicable to nursing practice.

Care Plan

A written document outlining the nursing care interventions designed to achieve specific client outcomes.

SMART Goals

Specific, Measurable, Achievable, Relevant, and Time-bound objectives for nursing care.

Collaboration

Working jointly with clients, families, and other healthcare professionals to provide optimal care.

Health Promotion

Actions aimed at improving client health and preventing disease.

Strengths Assessment

Identifying positive attributes and resources that support client health.

Stressors

Factors that disrupt a client’s equilibrium or contribute to health problems.

Interventions

Actions taken by nursing professionals to enhance client care and outcomes.

Outcomes Measurement

The evaluation of whether nursing actions achieved the intended effects on client health.

Documentation

The process of accurately recording client care and outcomes.

Health Record Review

Assessing a client's medical history and prior health records for relevant information.

NANDA

North American Nursing Diagnosis Association; provides standardized nursing diagnosis terminology.

Goal Setting

The process of defining specific, measurable objectives for client care.

Nursing History

A comprehensive overview of the client's previous health status, problems, and care.

Bio-psychosocial Model

A model that considers biological, psychological, and social factors in health and illness.

Human Response

The way individuals react to health stressors or environmental changes.

Goal Attainment

The successful achievement of desired health outcomes.

Quality Assurance

Processes used to monitor and improve the quality of care provided.

Critical Thinking

The ability to analyze and evaluate information for effective decision making in nursing.

Intra-personal Factors

Influences on a person's health that arise from within the individual, such as physical and mental health.

Inter-personal Factors

Influences on a person's health from relationships with others, such as family and peer support.

Extra-personal Factors

Environmental influences on health, including community and societal factors.

Client Engagement

Active participation of the client in their care process.

Therapeutic Communication

The use of communication techniques that help build rapport, trust, and therapeutic relationships with clients.

Evidence-Based Practice

Using the best available evidence to inform clinical decision making.

Care Coordination

Organizing client care activities and sharing information among participants to achieve safer and more effective care.

Patient-Centered Care

Care that is respectful of and responsive to individual patient preferences, needs, and values.

Outcome Criteria

Specific data points that indicate successful client outcomes in relation to nursing interventions.

Holistic Nursing

An approach that considers the whole person—body, mind, spirit, and environment—in the care provided.

Functional Assessment

Measuring a client's ability to perform activities of daily living.

Chronic Illness Management

Strategies to help clients manage long-term health conditions.

Documentation Standards

Guidelines for maintaining records that ensure quality and legal compliance.

Referrals

The process of directing a client to other healthcare services for additional care.

Nursing Practice Act

Laws governing the practice of nursing, defining the scope and responsibilities of nursing.

Client Education

Providing information and skills to clients to help them manage their health effectively.

Measurable Outcomes

Specific criteria that can be quantified to assess the success of care interventions.

Behavioral Objectives

Goals that specify observable actions or behaviors by the client.

Documentation Accuracy

Ensuring that all written records of client care are correct and up-to-date.

Intervention Rationale

The reasoning behind each nursing action taken in the care plan.

Outcome Evaluations

Assessing whether the client outcomes match the expected results.

Patient Autonomy

The right of clients to make informed choices about their personal care.

Standard Precautions

Infection control practices used to prevent transmission of diseases.

Caring Science

The study and practice of nursing care through the lens of caring.

Cross-Disciplinary Collaboration

Working together across different healthcare professions to deliver comprehensive care.

Nursing Pathway

A predetermined care strategy for patients with specific clinical needs.

Safety Measures

Actions taken to prevent harm or injury to clients during healthcare delivery.

Outcome Measurement Tools

Instruments used to assess the effectiveness of interventions and client outcomes.

Cultural Competency

Awareness and respect for different cultural practices and beliefs in healthcare.

Continuity of Care

Ensuring that clients receive consistent care across different healthcare settings.

Critical Care Nursing

A specialty focused on the complex needs of critically ill patients.

Home Health Care

Medical and therapeutic services delivered in a client's home.

Community Health Nursing

Nursing practice focused on the health of populations and community wellness.

Preventive Care

Healthcare services aimed at preventing illness or promoting health.

Clinical Pathway

A standardized, evidence-based approach to treatment for a specific condition.

Patient Safety

The prevention of errors and adverse effects to patients associated with healthcare.

Transitional Care

Care provided during transitions between different settings or levels of care.

Health Literacy

The degree to which individuals can obtain, process, and understand basic health information.

Informed Consent

The process of providing information about a treatment or procedure so the patient can make an educated decision.

Chronic Care Model

A framework designed to improve chronic illness management and outcomes.

Patient Advocacy

Supporting and promoting the rights of patients within the healthcare system.

Resource Allocation

The distribution of available resources in nursing to provide effective care.

Quality Improvement

Ongoing efforts to improve the standard of care in healthcare settings.

Health Economics

The study of how healthcare resources are allocated and utilized.

Legislation Impact

The influence of laws and regulations on nursing practice.

Capstone Projects

Culminating experiences in nursing education where students apply learned concepts.

Mentorship in Nursing

Guidance and support provided to novice nurses by experienced professionals.

Professional Re-certification

The process of renewing nursing credentials to maintain licensure.

Interprofessional Education

Training that brings together students from different health professions to learn collaboratively.

Patient Surveys

Tools used to gather feedback from clients about their experiences with care.

Public Health Initiatives

Programs designed to improve the health of populations at large.

Healthcare Policy

Allocated guidance that determines the health service outcomes.

Clinical Practice Guidelines

Evidence-based recommendations to assist healthcare professionals in decision making.

Communication Technology

Tools used to enhance communication in healthcare settings.

Nursing Informatics

The use of information technology in the management of nursing practice.

Emotional Support

Providing psychological comfort and reassurance to clients.

Skill Competence

The ability to perform nursing skills proficiently and safely.

Continuing Nursing Education

Ongoing education required for nurses to maintain knowledge and skills.

Healthcare Quality Assurance

Processes in place to ensure health services are provided effectively and safely.

Patient Referral Processes

The protocols followed to send patients to specialists or other health services.

Case Management

A collaborative approach to plan, coordinate, and manage healthcare services.

Health Improvement Strategies

Plans designed to enhance the health of individuals or communities.

Ethics in Nursing

The moral principles that govern a nurse's conduct in their practice.