NUR 102 Exam 1, Week 3: Terms Flashcards

1
Q

Aggressive Behavior

A

Standing up for one’s rights in a negative manner that violates the rights of others.

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2
Q

Assertive Behavior

A

Ability to stand up for oneself and others using open, honest, and direct communication.

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3
Q

Body Language

A

Non-verbal communication.

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4
Q

Channel

A

Denote the medium selected to convey the message; the channel may target any of the receiver’s senses.

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5
Q

Cliché

A

Stereotyped, trite, or pat answer.

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6
Q

CUS (Communication Tool)

A

Tool to assist in effective communication related to patient safety concerns; the acronym CUS stands for I’m Concerned, I’m Uncomfortable, This is unSafe (or this is a Safety issue).

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7
Q

Empathy

A
  • Objective understanding of the way in which a patient sees his or her situation, identifying with the way another person feels, putting oneself in another person’s circumstances and imagining what it would be like to share that person’s feelings;
  • Intellectually identifying with the way another person feels
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8
Q

Feedback

A

Verbal and non-verbal evidence that the message is received and understood.

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9
Q

Group Dynamics

A

Study of a group’s characteristics and ways of functioning.

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10
Q

Helping Relationship

A

Interaction that sets the climate of movement of the participants toward common goals.

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11
Q

Horizontal Violence

A

Anger and aggressive behavior between nurses or nurse-to-nurse hostility.

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12
Q

Incivility

A

Rude, intimidating, and undesirable behavior directed at another person.

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13
Q

Interpersonal Communication

A

Communication that occurs between two or more people with a goal to exchange messages.

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14
Q

Intrapersonal Communication

A

Communication techniques or self-talk to enhance positive interaction with the patient and family.

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15
Q

Organizational Communication

A

Process of communication that involves individuals and groups to achieve established goals.

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16
Q

Rapport

A

Feeling of mutual trust experienced by people in a satisfactory relationship.

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17
Q

Semantics

A

Study of the meaning of words.

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18
Q

Small-Group Communication

A

Communication that occurs when two or more nurses interact with two or more individuals, allowing the members to achieve a goal through communication.

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19
Q

Bedside Report

A

Standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family.

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20
Q

Change-of-Shift Report

A

Communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped.

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21
Q

Charting By Exception (CBE)

A

Shorthand method for documenting patient data that are based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes.

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22
Q

Confer

A

To consult with someone to exchange ideas or to seek information, advice, or instructions.

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23
Q

Consultation

A

Process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution.

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24
Q

Critical/Collaborative Pathway

A

Case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions.

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25
Q

Discharge Summary

A

Description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals.

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26
Q

Flow Sheet

A

Graphic record of abbreviated aspects of the patient’s condition (e.g., vital signs, routine aspects of care).

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27
Q

Focus Charting

A

Documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion of focus charting uses the data (D), action (A), response (R) format.

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28
Q

Graphic Record

A

Form used to record specific patient variables.

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29
Q

Handoff

A

Nurse’s report to another nurse or health care provider about a patient’s status and progress.

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30
Q

Health information Exchange (HIE)

A

Electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information.

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31
Q

Incident Report

A

Report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor.

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32
Q

ISBAR Communication

A

Process for effective handoff communication among health care professionals about a patient’s condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

33
Q

Minimum Data Set

A

Standard established by health care institutions that specifies the information that must be collected from every patient.

34
Q

Narrative Notes

A

Progress notes written by nurses in a source-oriented record.

35
Q

Occurence Charting

A

Documentation when a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate; typically used for variances that affect quality, cost, or length of stay.

36
Q

Outcome and Assessment Information Set (OASIS)

A

Assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided.

37
Q

PIE Charting

A

Documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)–intervention (I)–evaluation (E) format, and evaluated each shift.

38
Q

Problem-Oriented Medical Record (POMR)

A

Documentation system organized according to the person’s specific health problems; includes database, problem list, plan of care, and progress notes.

39
Q

Progress Notes

A

Any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes.

40
Q

Purposeful Rounding

A

Proactive, systematic, nurse-driven, evidence-based intervention that helps nurses anticipate and address patient needs.

41
Q

Read-Back

A

Process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted.

42
Q

SOAP Format

A

Method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P).

43
Q

Source-Oriented Record

A

Documentation system in which each health care group records data on its own separate form.

44
Q

Variance Charting

A

Documentation method in case management when a patient fails to meet an expected outcome or when a planned intervention is not implemented that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate; typically used for variances that affect quality, coast, or length of stay; also called occurrence charting.

45
Q

Variance Report

A

Tool used by health care facilities to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor; also called an incident report or occurrence report.

46
Q

Big Data

A

Accumulation of data from various sources, combined with new technologies that allow for the transformation of data to information.

47
Q

Clinical Information System (CIS)

A

Computer-based system designed for collecting, storing, manipulating, and making available clinical information important to the health care delivery process.

48
Q

Genomics

A
  • Study of the structure and interactions of all genes in the human body, including their interactions with each other as well as the environment;
  • Emerging discipline in which genomic information about a person is used in their clinical care (e.g., for diagnostic or therapeutic decision making)
49
Q

Health Information Technology (IT)

A

Standard and agreed upon terms used in an electronic health record to improve data trending and sharing.

50
Q

Interoperability

A

Ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user.

51
Q

Meaningful Use

A

Use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid.

52
Q

Nurse Informacist

A

Specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

53
Q

Nursing Informatics (NI)

A

Specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

54
Q

Optimization

A

Strategies to improve processes, maximize effective use, reduce errors, reduce costs, eliminate workflow inefficiencies, improve clinical decision support, and improve end-user skills and satisfaction with the system.

55
Q

Pharmacogenomics

A

Use of information about a person’s genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that person.

56
Q

Predictive Analytics

A

Variety of statistical techniques that analyze current and historical facts to make predictions about future or otherwise unknown events.

57
Q

Standard Terminology

A

Standard and agreed upon terms used in an electronic health record to improve data trending and sharing (refer to Table 20-5).

58
Q

System Development Life Cycle (SDLC)

A

Development cycle for an information technology system that includes the following phases:

  • Analyze and plan
  • Design
  • Test
  • Train
  • Implement
  • Maintain
  • Evaluate
59
Q

Telecare

A

Technologies that provide for patient safety and independence at home, such as health and fitness apps, sensors and tools that connect the patient with caregivers, digital medication reminder systems, and early warning and detection technologies.

60
Q

Telehealth

A

Use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration.

61
Q

Telemedicine

A

Use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners.

62
Q

Usability

A

Extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.

63
Q

Active Exercise

A

Joint movement activated by the person.

64
Q

Atrophy

A

Decrease in the size of a body structure.

65
Q

Contractures

A

Permanently contracted state of a muscle.

66
Q

Ergonomics

A

Practice of designing equipment and work tasks to conform to the capability of the worker and providing a means for adjusting the work environment and work practices to prevent injuries.

67
Q

Flaccidity (Hypotonicity)

A

Decreased muscle tone.

68
Q

Footdrop

A

Complication resulting from extended plantar flexion.

69
Q

Isokinetic Exercise

A

Exercise involving muscle contractions with resistance varying at a constant rate.

70
Q

Isometric Exercise

A

Exercise in which muscle tension occurs without a significant change in muscle length.

71
Q

Isotonic Exercise

A

Movement in which muscles shorten (contract) and move.

72
Q

Orthopedics

A

Correction or prevention of disorders of body structures used in locomotion.

73
Q

Paresis

A

Impaired muscle strength or weakness.

74
Q

Paralysis

A

Absence of strength secondary to nervous impairment.

75
Q

Passive Exercise

A

Manual or mechanical means of moving the joints.

76
Q

Patient Care Ergonomics

A

Practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care.

77
Q

Range of Motion

A

Complete extent of movement of which a joint is normally capable.

78
Q

Spasticity

A

Increased muscle tone.

79
Q

Tonus

A

Normal, partially steady state of muscle contraction.