The Nursing Process - Fall 2026

Flashcards covering the components, definitions, and ethical principles of the Nursing Process and Critical Thinking based on the Fall 2026 lecture by S. Hicks.

Nursing Process

A five-step critical thinking process developed by the American Nurses Association (ANA) that includes Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The systematic and deliberate collection of information regarding a client's current and past health status, functional status, and coping patterns.

Critical Thinking

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process.

Subjective Data

Information provided by the patient, who is considered the primary source for information.

Objective Data

Information that is observed or measured by the nurse during the assessment.

Orientation Phase

The first phase of a patient-centered interview where the nurse introduces themselves, explains the purpose, and sets the agenda.

Working Phase

The phase of the interview dedicated to collecting the assessment data through observation and communication.

Termination Phase

The final phase of the interview where the nurse summarizes the findings to conclude the interaction.

Backchanneling

An interview technique using phrases like "all right" or "go on" to indicate the nurse is listening and encourages the patient to continue.

Autonomy

An ethical principle involving decision making and advocating for the patient's choices.

Beneficence

An ethical principle where actions are guided by compassion.

Non-maleficence

An ethical principle meaning to "do no harm."

Justice

An ethical principle defined as fairness and equality.

PQRST

An acronym used to assess illness or concerns: Provokes, Quality, Radiates, Severity ($0-10$), and Time.

Nursing Diagnosis

A clinical judgment made by a Registered Nurse describing a response or vulnerability of a health condition that can be treated.

NANDA-I

North American Nursing Diagnosis Association International, the body that approves nursing diagnosis labels.

Problem-Focused Nursing Diagnosis

A diagnosis identifying an undesirable human experience that includes a diagnostic label, related factors, and major defining characteristics.

Risk Diagnosis

A negative diagnosis regarding the increased potential for complications, consisting of the diagnosis and associated risk factors preceded by the phrase "evidenced by."

Health Promotion Nursing Diagnosis

A positive diagnosis representing the desire and motivation to improve health, consisting of the diagnosis label and defining characteristics.

High Priority

A classification for nursing diagnoses that, if left untreated, will cause harm or death, such as issues with airway, breathing, circulation, or safety.

SMART Acronym

A guide for setting nursing outcomes: Specific, Measurable, Attainable, Realistic, and Timed.

Nurse-initiated Interventions

Independent nursing actions that do not require an order, such as positioning, providing education, or helping with mobility.

Dependent Nursing Interventions

Interventions initiated by healthcare providers that require an order for the nurse to perform.

QSEN

An acronym for Quality & Safety Education for Nurses, which includes: Patient-Centered Care, Teamwork and Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics.

ISBAR

A standardized communication tool for hand-offs: Identify, Situation, Background, Assessment, and Recommendation.

Direct Care

Treatments performed through interactions with patients, including ADLs, lifesaving measures, and counseling.

Indirect Care

Nursing actions performed away from the patient but on their behalf, such as documentation, delegation, and infection control.

Preventable Adverse Events

Events that occur due to an error or a failure to apply an accepted strategy for prevention.

Ameliorable Adverse Events

Events that are not preventable but could have been less harmful with a different clinical pathway.

Evaluation

The final step of the nursing process where the nurse monitors clinical progression and compares results to the expected outcome criteria.