Nursing Process Overview

These flashcards cover key terms and definitions related to the nursing process as outlined in the lecture notes.

Nursing Process

A systematic approach to patient care that involves five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The first step in the nursing process involving the collection and analysis of patient information to establish a database.

Subjective Data

Information that is reported by the patient that cannot be verified, such as feelings and perceptions.

Objective Data

Information that can be observed or measured, such as vital signs and physical examinations.

Nursing Diagnosis

Clinical judgment about a patient’s response to health conditions or needs that a nurse is licensed to treat.

Planning

The third step in the nursing process focused on setting patient-centered goals and identifying appropriate nursing interventions.

Implementation

The fourth step in the nursing process where planned nursing interventions are performed.

Evaluation

The final step in the nursing process where the nurse assesses the patient's progress toward the goals.

Cues

Information obtained through the senses that guide the nurse in making inferences.

Inferences

The nurse's judgment or interpretation based on the collected cues.

Types of Nursing Diagnoses

Includes Problem-Focused, Risk, and Health Promotion diagnoses.

Data Validation

The process of comparing collected assessment data with other sources to ensure accuracy.

Cultural Considerations

Understanding the patient's cultural background, values, and beliefs to provide sensitive care.

SMART Goals

Specific, Measurable, Attainable, Realistic, Timed goals set for patient care.

Critical Thinking

The ability to analyze and interpret data to inform decisions in nursing practice.

Patient-Centered Interview

An organized conversation with the patient designed to gather information and build a therapeutic relationship.

Assessment Tool

A structured form for collecting comprehensive patient data.