Exam 2 Comprehensive Study Notes on EBP, Nursing Process, and Prioritization

Vocabulary flashcards focusing on the steps of the nursing process (ADPIE), types of assessment data, diagnostic distinctions, and care planning principles.

ADPIE

An acronym representing the sequential steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The systematic and continuous collection of patient data, including vital signs, physical examination, health history, and changes in condition.

Objective Data

Unchangeable, factual clinical findings obtained by the healthcare provider, such as laboratory values, vital signs, and physical assessment collections.

Subjective Data

Information reported directly by the patient regarding what they feel or experience, such as pain, nausea, or numbness.

Focused Assessment

A targeted evaluation of a specific body system or area, typically performed in specialty areas or when a patient's status is challenged.

Nursing Diagnosis

A clinical identification of a patient problem or risk (such as impaired gas exchange or risk for falls) that falls within the nursing scope of practice.

Medical Diagnosis

A formal diagnosis made strictly by a physician or advanced practice nurse identifying a disease process, which takes priority over a nursing diagnosis.

Planning

The phase of the nursing process where achievable patient outcome goals are set and strategies are determined with members of the healthcare team.

SMART Goals

Patient outcome goals designed to be Specific, Measurable, Attainable, Realistic, and Timely.

Implementation

The execution phase of the nursing process involving direct nursing actions, carrying out interventions, and carrying out physician orders.

Evaluation

The step in the nursing process where the nurse reassesses the patient to determine if interventions were effective and if established goals were met.

High Fowler's Position

Positioning a patient sitting upright at a $90$-degree angle, commonly used to improve respiratory status.

Acute Problem

A short-term health condition or issue characterized by a new onset.

Chronic Problem

A pre-existing, long-standing health issue that a patient has experienced over an extended period.