Nursing Care
The practice of helping individuals maximize their potential to maintain independence and meet
their self-care needs.
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment
The first step of the nursing process, aimed at identifying the patient's problems through
comprehensive data collection.
Head-to-Toe Assessment
A format of nursing assessment that involves a systematic examination of the patient's body
from head to toe.
Body Systems Assessment
A nursing assessment format that focuses on evaluating specific body systems to identify health
issues.
Gordon's Functional Health Patterns Model
A framework used in nursing assessments that categorizes health patterns to assess a patient's
functional health.
Nursing Diagnosis
A statement that identifies human response patterns that nurses can treat, distinct from
medical diagnoses.
Medical Diagnosis
A determination made by a healthcare provider that identifies a disease or condition affecting a
patient.
, Actual Nursing Diagnosis
A type of nursing diagnosis that describes a current health problem or condition.
Risk/High-Risk Nursing Diagnosis
A nursing diagnosis that indicates a potential problem that may develop in a patient.
Health Promotion/Wellness Nursing Diagnosis
A diagnosis that focuses on a patient's readiness to enhance their health and well-being.
Syndrome Nursing Diagnosis
A diagnosis that represents a cluster of nursing diagnoses that occur together.
Risk for Impaired Skin Integrity
An example of a Risk/High-Risk Nursing Diagnosis related to immobility.
Planning Phase
The phase of the nursing process that involves setting priorities, developing measurable goals,
and formulating nursing interventions.
Measurable Goal Statement
A specific goal in a care plan that begins with an action verb and outlines a behavior to be
performed within a specified timeframe.
Dependent Nursing Actions
Actions that require a provider's order before they can be performed.
Interdependent Nursing Actions
Actions that involve collaboration with other healthcare team members.
Independent Nursing Actions
Actions that nurses can initiate and perform without a provider's order.
Evaluation Phase
The phase of the nursing process that assesses whether the expected patient outcomes were
achieved.
Patient Education Considerations