Nursing Process Overview

A systematic method used to identify and address a patient's health needs. Includes assessment, diagnosis, planning, implementation, and evaluation.

Information or facts about a patient used to identify health problems, plan care, and evaluate outcomes.

Information gathered directly from the patient, such as their statements or physical observations.

Information gathered from sources other than the patient, like medical records or family members.

A comprehensive assessment that includes a complete health history and physical exam.

Focuses on a specific problem or issue, gathering just enough information to address it.

Ongoing assessment to monitor progress and evaluate the effectiveness of interventions.

Rapid assessment done concurrently with lifesaving measures in a critical situation.

Gathering information directly from the patient about their health and experiences. This includes their subjective feelings, symptoms, and perspectives.

A tool used to organize and connect cues and problems in a patient's case. It helps to visualize the relationships between different factors.

The most likely cause or contributing factor to a nursing diagnosis. It helps in understanding why a patient is experiencing a particular problem.

A process of grouping significant cues or pieces of information together to identify patterns and potential problems.

A systematic and structured approach to interviewing patients, which includes building rapport, gathering information, and providing education.

The process of identifying and analyzing a patient's health needs.

A structured conversation between a nurse and a patient to collect information about their health.

A systematic observation using your senses to gather data about a patient's physical appearance, behavior, and environment.

A physical examination technique that involves using your hands to feel for textures, shapes, sizes, and temperatures.

A physical examination technique that involves tapping on a patient's body to listen for sounds that indicate the density of underlying tissues.

A physical examination technique that involves listening to sounds produced by the body using a stethoscope.

Comparing and verifying information from different sources to ensure accuracy and completeness of patient data.

Organizing and clustering collected data to identify patterns and relationships, helping to interpret the patient's condition.

Accurate, factual information about a patient's condition, recorded directly by the nurse.

Specialized tools or models that guide nurses in systematically gathering patient data.

A systematic approach to collecting data based on examining each body system, from head to toe.

A comprehensive framework by Jarvis, incorporating health history, physical exam, and nursing history.

Clinical Judgement: Recognizing cues, generating and weighing hypotheses, taking actions and evaluating

The process of analyzing patient data to draw conclusions about their health status.

Interpreting data to identify patient needs and problems.

Specific pieces of information about a patient, like vital signs or symptoms.

The patient's reason for seeking medical attention, expressed in their own words or specific symptoms. It can be followed by an assessment using the PQRSTU method to further understand the symptom.

A detailed account of the patient's general health over the past 5-10 years. Includes information like major childhood illnesses, hospitalizations, surgical procedures, pregnancy history, immunizations, allergies, and current medications.

Information about the health status of relatives, especially those with blood ties. Includes age, health condition, and cause of death for immediate family members.

A quick assessment of the patient's overall health, covering various body systems. It's subjective, meaning it relies on the patient's reports rather than physical findings.

A set of questions and observations focusing on how the patient performs daily activities, including aspects like self-esteem, sleep, stress management, and alcohol/substance use.

The outer layer of skin, responsible for protection, preventing penetration, sensing touch, regulating temperature, and other functions. It's composed of the epidermis and dermis.

Abnormal changes in skin color, including paleness, redness, blueness, or yellowing. These changes can be indicative of underlying health conditions.

A condition where excess fluid accumulates beneath the skin, causing swelling. It's assessed using a scale based on the depth and duration of the indentation formed after pressing on the skin.

Any visible abnormality on the skin, characterized by features like color, elevation, shape, size, location, and the presence of any fluid discharge.

Skin conditions affecting children, including diaper dermatitis, eczema, impetigo, and measles.

A type of skin cancer developing in the basal layer of the epidermis. It's characterized by slow growth and is often treatable.

An evaluation of moles using the ABCDE method to assess for potential melanoma, a serious type of skin cancer.

Injuries to the skin that occur over bony prominences due to impaired circulation, usually in bedridden patients. These are categorized by stages (I-IV) indicating the depth of the wound.

The bones of the skull, including frontal, parietal, occipital, and temporal bones. These form the protective structure for the brain.

The junction or seam where two cranial bones join together. Examples include the coronal, sagittal, and lambdoid sutures.

The prominent muscles located on either side of the neck, responsible for head movement and rotation. These muscles are commonly used for ROM testing.