The Nursing Process & Clinical Reasoning/Judgment

Vocabulary flashcards covering the core concepts of the Nursing Process and Clinical Reasoning/Judgment lecture at the University of Kentucky College of Nursing.

Nursing Process

A patient-focused five-step systematic method used by nurses to provide care, consisting of Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Assessment

The first step of the nursing process involving the collection and evaluation of information (data) and finding cues about a patient's condition.

Primary Patient Data

Health assessment information obtained directly from the patient.

Secondary Patient Data

Assessment information collected from anyone or anything other than directly from the patient, such as family members or medical records.

Subjective Data

Patient-reported symptoms directly stated by the patient that cannot be independently measured or observed by the nurse (e.g., pain rating, feeling dizzy, feeling tired).

Objective Data

Observable and measurable signs collected through physical assessment, vital signs, laboratory results, and diagnostic tests.

Diagnosis (Nursing Diagnosis)

The step of the nursing process where the nurse analyzes cues, identifies actual and potential health problems, formulates problem statements, and prioritizes them.

Planning

The step of the nursing process that involves establishing broad patient-centered goals and measurable SMART outcomes/objectives in collaboration with the patient.

SMART Objectives

Specific, Measurable, Achievable, Relevant, and Time-bound objectives created in collaboration with the patient to evaluate whether a patient-centered goal is achieved.

Implementation

The step of the nursing process where the nurse carries out the specific nursing interventions and actions defined during planning.

Independent Nursing Interventions

Nursing actions that a nurse can execute autonomously without a healthcare provider's order (e.g., assessing vital signs, patient education, positioning).

Interdependent Nursing Interventions

Collaborative nursing actions carried out in cooperation with other members of the interprofessional healthcare team (e.g., physical therapy, pharmacy, lactation services).

Dependent Nursing Interventions

Nursing actions that require an order or directive from a licensed physician or healthcare provider (e.g., administering prescribed medications, drawing blood labs, ordering imaging).

Evaluation

The ongoing systematic step of the nursing process where the nurse reassesses the patient to determine if goals and SMART objectives were met, partially met, or not met, revising the care plan as needed.

Clinical Reasoning

The nurse-focused cognitive process describing how nurses think, analyze patient cues, and process information prior to decision-making.

Clinical Judgment

The nurse-focused decision-making outcome describing how nurses decide to act based on clinical reasoning.

Clinical Judgment Model Steps

A six-step nurse-focused process: Recognize cues, Analyze cues, Prioritize hypotheses, Generate solutions, Take action, and Evaluate outcomes.

Maslow's Hierarchy of Needs

A prioritized hierarchy of human needs used in nursing, moving from physiological needs (air, water, food, shelter, sleep, clothing, reproduction) at the base up through safety, love and belonging, esteem, and self-actualization.