Nursing Care Plans and Process

These flashcards cover key concepts related to nursing care plans, including the nursing process and related terminology.

Nursing Process

A systematic approach used by nurses to provide patient care, defined by steps that are cyclical and dynamic.

Cyclical

Refers to the repetitive nature of the nursing process, where each step is continuously revisited as patient conditions change.

Dynamic

Indicates that the nursing process is ever-changing to accommodate the varying needs of patients.

Patient-Centered Care

An approach that involves including patients in their own care plans and decision-making.

Subjective Data

Information that is provided by the patient, based on their own experiences and feelings.

Objective Data

Measurable and observable information collected by the nurse through assessment.

Assessment

The first step in the nursing process, involving the collection of patient data through interviews and physical examinations.

Diagnosis

The second step in the nursing process; identifying the patient's problem or health status based on assessment data.

SMART Goals

A framework for setting patient goals that are Specific, Measurable, Attainable, Relevant, and Timely.

Interventions

Actions taken by nurses to meet the goals outlined in the nursing care plan.

Collaborative Interventions

Care activities that involve other healthcare professionals in addition to the nurse.

Evaluation

The last step in the nursing process; assessing the effectiveness of the care plan and making necessary adjustments.

Independent Interventions

Nursing actions that can be initiated without the need for physician orders.

Dependent Interventions

Nursing actions that require a physician's orders before being implemented.

Wellness Diagnosis

Identifies a patient's readiness for enhanced health or wellness, rather than a specific health problem.

Risk Diagnosis

Identifies potential problems a patient may face due to various risk factors.

Critical Thinking

The cognitive process that nurses use to assess patient data and make clinical decisions.