Chapter 3: The Nursing Process, Clinical Reasoning, and Care Planning

Sixty vocabulary-style flashcards covering the nursing process, clinical reasoning, and prioritization methods derived from the lecture transcript.

Nursing Process

A systematic, organized method nurses use to identify client needs, provide individualized care, and evaluate whether care was effective.

Assessment

The first step of the nursing process where the nurse collects information about the client.

Client Database

A complete collection of health information used to make nursing decisions, upon which every other step depends.

Nursing Analysis

The process of interpreting assessment findings to identify nursing problems and determine client responses to health problems.

Planning

The formal step involving establishing priorities, goals, and nursing interventions.

Nursing Intervention

An action the nurse performs to achieve client outcomes, such as teaching, monitoring, or giving medication.

Implementation

Carrying out nursing interventions safely, including reassessing the client and documenting care.

Evaluation

The step of determining if goals were achieved and whether the intervention worked.

Collaborative Problem

A health complication requiring both nursing interventions and provider treatment.

Expected Outcome

A measurable goal for the client that describes what they will accomplish.

Clinical Reasoning

Using nursing knowledge to make decisions about patient care for one specific client.

Critical Thinking

A broad logical process used to solve problems, involving analysis, reflection, and decision making.

Concept Care Mapping

A visual organization of nursing care that connects diagnosis, assessment findings, analyses, interventions, and outcomes.

AAPIE

A mnemonic for the five steps of the nursing process: Assessment, Analysis, Planning, Implementation, and Evaluation.

Subjective Data

Information the client tells the nurse that cannot be measured directly, such as "$8/10$" pain or feeling dizzy.

Objective Data

Information the nurse can observe or measure, such as blood pressure, respiratory rate, and laboratory results.

Primary Source

The client, who is the main source of assessment information.

Secondary Sources

Information gathered from family, medical records, previous nurses, laboratory reports, or diagnostic tests.

Medical Diagnosis

A diagnosis that identifies the specific disease a client has, such as Diabetes or Pneumonia.

Problem-Focused Nursing Analysis

An analysis of a problem that already exists, supported by signs and symptoms.

Risk Nursing Analysis

An analysis identifying a problem the client is at risk of developing, which does not include "as evidenced by" symptoms.

Syndrome Analysis

A type of analysis used when several nursing problems occur together, such as Disuse Syndrome.

Health Promotion Analysis

A nursing analysis focused on wellness, such as readiness for enhanced nutrition.

ABCs Priority Rule

The prioritization rule stating that Airway, Breathing, and Circulation always come first.

Maslow's Hierarchy of Needs

A prioritization framework progressing from physiological needs to safety, love, esteem, and self-actualization.

Actual before Risk Priority

A rule stating that existing problems should be addressed before potential risk factors.

Acute before Chronic Priority

A prioritization rule stating that sudden, rapid-onset conditions take precedence over long-term issues.

Unstable before Stable Priority

A rule prioritizing clients with fluctuating conditions over those who are steady.

Life-threatening before Non-life-threatening

The prioritization rule focusing on the most immediate dangers to the client's life.

SMART - Specific

The "S" in SMART goals, meaning the outcome must be detailed.

SMART - Measurable

The "M" in SMART goals, meaning progress can be quantified, such as pain reported as "$3/10$" or less.

SMART - Achievable

The "A" in SMART goals, meaning the goal is realistic for the client.

SMART - Relevant

The "R" in SMART goals, meaning the goal is applicable to the client's current health situation.

SMART - Time-bound

The "T" in SMART goals, meaning the goal includes a specific timeframe for completion.

Golden Rule of Documentation

The legal standard stating: "If it wasn't documented, it wasn't done."

Outcome Met

An evaluation result where the plan worked and may be continued or discontinued as appropriate.

Outcome Partially Met

An evaluation result requiring the nurse to revise the care plan.

Outcome Not Met

An evaluation result requiring the nurse to reassess the client and modify the care plan.

PES Framework

A mnemonic for the parts of a nursing analysis: Problem, Etiology (cause), and Signs & Symptoms.

LPN Assessment Role

Collecting focused assessment data and reporting findings.

RN Assessment Role

Performing the comprehensive assessment of the client.

LPN Analysis Role

Reporting findings and abnormal data to the health care team.

RN Analysis Role

The responsibility of establishing the nursing analysis.

LPN Planning Role

Assisting with the development of the client's care plan.

RN Planning Role

The lead responsibility for developing the care plan.

LPN Implementation Role

The responsibility of performing nursing interventions.

RN Implementation Role

Managing and delegating nursing care.

LPN Evaluation Role

The responsibility of reporting client responses to interventions.

RN Evaluation Role

The responsibility of evaluating and revising the care plan based on client outcomes.

Reassessment

A critical implementation step involving checking the client's status immediately before performing an intervention.

As Evidenced By

A phrase used in problem-focused nursing analyses to present physical evidence like a fever of "$101.8^\circ F$".

Etiology

The cause of a nursing problem (the "E" in the PES framework).

Specific Intervention Detail

The requirement that interventions be detailed, such as offering "$30\,mL$" of water every hour.

Health History

A component of assessment involving the collection of historical health data and nursing history.

Review of Systems

A systematic assessment component evaluating various physiological systems.

Psychosocial Assessment

An assessment component focused on the client's mental and social well-being.

Vital Signs

Objective assessment markers including blood pressure, temperature, heart rate, and oxygen saturation.

Evidence of Infection Example

Clinical findings such as a "$101.8^\circ F$" fever, redness, and yellow drainage used to support a nursing analysis.

Risk for Infection Example

A nursing analysis for a client with an indwelling catheter but no current symptoms of fever or redness.

Documentation Purposes

To communicate care, provide legal protection, support reimbursement, and improve continuity of care.