Introduction to the Nursing Process, Assessment, and Nursing Diagnosis

A set of vocabulary flashcards covering key definitions, principles, and steps of the Nursing Process, Assessment, and Nursing Diagnosis based on Chapters 5, 6, and 7.

Nursing process

The foundation of professional nursing practice and the framework within which nurses provide care to patients in an organized and effective manner, requiring critical thinking.

Lydia Hall

The individual who first used the term 'nursing process' in 1955.

American Nurses Association (1973)

Identified five specific steps of the nursing process in its Standards of Clinical Practice in 1973.

Characteristics of the Nursing Process

Analytical, dynamic, organized, outcome oriented, collaborative, and adaptable.

Assessment

An organized and ongoing appraisal of a patient's well-being utilizing a holistic approach.

Nursing diagnosis

A description of what a nurse observes or discovers while assessing a patient or group, which identifies a problem, potential problem, or opportunity for improvement.

Planning

The step of the nursing process that prioritizes hypotheses and patient or group nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions.

Implementation

The initiation of appropriate actions and interventions designed to meet the unique needs of each patient or group.

Evaluation

The response to nursing interventions and goal or outcome attainment.

Methods of Assessment (Observation)

Data collection via sight, hearing, and smell.

Primary data

Information obtained directly from the patient.

Secondary data

Information shared by family members, friends, or other members of the health care team.

Subjective data

Spoken information or symptoms that are difficult to validate.

Objective data

Signs that can be measured or observed.

Patient Interview Phases

The orientation phase, working phase (health history, review of systems, health promotion), and termination phase.

Physical Assessment Methods

Inspection, palpation, percussion, and auscultation.

Types of Physical Assessment

Comprehensive assessment, focused assessment, and emergency assessment (triage).

Data Organization Models

Frameworks including Body Systems Model, Head-To-Toe Model, and Gordon's Functional Health Patterns.

Nursing Taxonomies

Systems used to classify nursing diagnoses, including NANDA International, Inc. (NANDA-I), International Classification for Nursing Practice (ICNP) by the ICN, and Clinical Care Classification System (CCC).

Problem-focused diagnostic label

A NANDA-I diagnosis label selected when there are identifiable patient or group responses to a current need, problem, or life process.

Risk nursing diagnosis label

A NANDA-I label selected when a patient or group is vulnerable to developing a complication or problem not already in existence.

Health promotion nursing diagnostic label

A NANDA-I label starting with the words 'Readiness for Enhanced' selected when a patient or group has expressed a desire for improved health status or behavior.

Diagnosis label

A concise term or phrase that represents a pattern of related, clustered data.

Related factors

The underlying cause or etiology supporting a problem-focused nursing diagnosis label.

Defining characteristics

Environmental, physical, psychological, or situational concerns, or clustered subjective and objective patient data used to support a nursing diagnosis.

Data clustering

Organizing patient assessment data into groupings with similar underlying causes.

Diagnostic validity

Reviewing available options from either the taxonomy in the EMR or the NANDA-I list to ensure accurate use of the diagnosis.