Nursing Process Flashcards

Study Notes

Key Concepts in Nursing Process

Subjective Data: Non-observable information derived from a patient's perspective; includes feelings, pain levels, and personal perceptions.
Objective Data: Observable and measurable information; includes diagnostic results, test findings, and data collected through physical examinations.

Five Steps of the Nursing Process

Assessment: A systematic approach for collecting and analyzing diverse data about a client, incorporating physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.
Diagnosis: A clinical conclusion about a patient's health status, identifying actual or potential health issues that necessitate nursing intervention; involves problem identification based on assessment data and risk factor evaluation.
Outcome (Goals): Establishing measurable and achievable goals for patient care, with realistic timelines (example: moving from bed to chair three times a day).
Intervention: Implementation of the agreed-upon care plan, executing nursing activities tailored to achieve patient goals.
Evaluation: Assessment of the effectiveness of nursing interventions and whether objectives have been met; critical for adjusting care plans as necessary.

Techniques for Assessment

Inspection: Visual examination of the patient for physical signs of health or illness.
Palpation: Use of touch to assess body structures and their characteristics beneath the skin.
Percussion: Tapping on body surfaces to create sounds that help evaluate underlying structures.
Auscultation: Listening to sounds produced within the body; can be performed directly with the ear or indirectly with a stethoscope.

Description

Review the five essential steps of the nursing process with these flashcards. Each card presents key terms related to subjective and objective data, which are vital for patient assessment. Enhance your understanding of nursing concepts and improve your clinical skills.