NCLEX-Style Nursing Process Vocabulary Flashcards

A collection of vocabulary flashcards covering key definitions, ADPIE steps, types of diagnoses, intervention categories, and outcome criteria from the Nursing Process lecture notes.

ADPIE

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

Assessment

The first step of the nursing process, which involves the collection, validation, and communication of patient data.

Diagnosis (Nursing Phase)

The step of the nursing process where the nurse analyzes assessment data to identify the patient's strengths and actual or potential health problems.

Planning

The step of the nursing process where the nurse establishes priorities, writes individualized SMART outcomes, selects evidence-based interventions, and communicates the plan of care.

Implementation

The step of the nursing process in which the plan of care is carried out, planned interventions are performed, and the patient is engaged in care.

Evaluation

The step of the nursing process that measures the effectiveness of care by comparing patient data with expected outcomes to determine whether to terminate, continue, or modify the plan.

Nursing Process

A systematic, dynamic, interpersonal, outcome-oriented, and universally applicable framework used by nurses to provide individual patient care.

Medical Diagnosis

A statement that identifies a specific disease process or injury and remains the same for as long as the disease is present.

Nursing Diagnosis

A clinical judgment that describes an actual or potential health problem that nurses treat within the nursing scope of practice, which can change as the patient's condition changes.

Problem-focused Diagnosis

A category of NANDA nursing diagnosis selected when a patient currently exhibits signs and symptoms supporting an existing health problem.

Risk Diagnosis

A category of NANDA nursing diagnosis used when a patient does not currently have a health problem but possesses vulnerability or high risk for developing one.

Health-promotion Diagnosis

A NANDA nursing diagnosis category focused on a patient's readiness to improve well-being and health potential.

SMART Criteria

An acronym used to ensure patient outcomes are properly written: Specific, Measurable, Attainable, Realistic, and Time-bound.

Nurse-initiated Intervention

An autonomous action performed by a nurse based on scientific rationale without requiring a provider order, such as repositioning a patient.

Physician-initiated Intervention

An action initiated by a provider's prescription or order that is carried out by the nurse, such as administering a prescribed medication.

Collaborative Intervention

An action carried out in cooperation with members of other health care disciplines, such as working with physical therapy to develop an ambulation plan.

Subjective Data

Information reported directly by the patient regarding their feelings, perceptions, or pain (e.g., patient reporting a headache rated 6/10).

Objective Data

Observable, measurable, and verifiable physical findings collected by the nurse (e.g., firm abdomen, rare bowel sounds, or moaning during palpation).

'Related to' Statement

The part of a three-part nursing diagnosis that identifies the etiology, cause, or contributing factor associated with the patient's nursing problem.

'As evidenced by' Statement

The part of a three-part nursing diagnosis that lists the defining characteristics, signs, symptoms, and assessment findings supporting the diagnosis.