Clinical Judgement and the Nursing Process Flashcards

Vocabulary flashcards covering key terms and concepts from Unit 1: Clinical Judgement and Nursing Application for Clinical Judgement.

Clinical Judgement

A systematic decision-making approach that nurses use to organize and provide patient care.

The Nursing Process

A universal, evidence-based approach to care consisting of Assessment, Diagnosis, (Outcomes Identification), Planning, Implementation, and Evaluation (ADPIE/ADOPIE).

NCSBN Clinical Judgement Measurement Model

A model outlining key steps in clinical decision-making: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.

Problem-Focused Nursing Diagnosis

A 3-part diagnostic statement that identifies an undesirable human response to existing problems or concerns, formatted as diagnostic label, related to statement, and defining characteristics.

Risk Nursing Diagnosis

A 2-part diagnostic statement applied when there is an increased potential or vulnerability for a patient to develop a problem, consisting of a diagnostic label and a related to statement without defining characteristics.

Health Promotion Nursing Diagnosis

A 1- or 2-part diagnostic statement established when a patient demonstrates the desire or motivation to enhance wellness and health status through positive behavioral change.

PES Format

The three-part structure used for problem-focused nursing diagnoses: Problem (diagnostic label), Etiology (related to statement), and Signs and Symptoms (defining characteristics).

Diagnostic Label

The standardized term or title describing the patient's human response or condition in a nursing diagnosis statement.

Related To Statement

The component of a nursing diagnosis statement that identifies the etiology or underlying factor contributing to a patient's problem or risk.

Defining Characteristics

The observable clinical cues, signs, and symptoms ('as evidenced by') that validate a problem-focused nursing diagnosis.

SMART Goals

A framework ensuring patient outcomes and goals are Specific, Measurable, Achievable, Relevant, and Time-bound.

Implementation

The step of the nursing process that begins once the plan of care is developed and includes all therapeutic, evidence-based direct and indirect care actions taken by the nurse.

Evaluation

The final step of the nursing process where the nurse compares current patient data against expected outcomes to determine if goals were met or if the plan of care needs revision.

Direct Care Interventions

Therapeutic nursing activities performed through direct contact with the patient, such as administering medications and providing patient education.

Indirect Care Interventions

Nursing actions performed away from the patient but on their behalf, such as documenting shift assessments, consulting physical therapy, or calling a homecare agency.

Syndrome Diagnosis

A clinical judgement concerning a specific cluster of nursing diagnoses that occur together and are best addressed together through similar interventions.

COPD

Chronic Obstructive Pulmonary Disorder, a respiratory medical condition referenced in care planning activities.

CVA

Cerebral Vascular Accident, also known as stroke.