Terms Flashcards
afebrile
“without fever” - a person with a normal body temperature
apnea
periods during which there is no breathing
blood pressure
the force of the moving blood against arterial walls
bradycardia
slow pulse rate (<60 bpm for adult)
bradypnea
slow rate of breathing
diastolic pressure
least amount of pressure exerted on arterial walls, which occurs when the heart is at rest between ventricular contractions
dyspnea
difficult or labored breathing
dysrhythmia
irregular pattern of heartbeats
eupnea
normal respiration (12-20 for adults)
febrile
a person with a fever
hypertension
blood pressure elevated about he upper limit of normal
hyperthermia
high body temperature (>105.8 F)
hypotension
blood pressure below the lower limit of normal
hypothermia
low body temperature (<97.0 F)
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released
orthopnea
type of dyspnea in which breathing is easier when the patient sits or stands
orthostatic hypotension
temporary fall in blood pressure associated with assuming an upright position
pulse
wave produced in the wall of an artery with each beat of the heart (normal is 60-100 bpm for adolescents & adults)
pulse deficit
difference between the apical and radial pulse rates
pulse pressure
difference between systolic and diastolic pressures
respiration
gas exchange between the atmospheric air in the alveoli and blood in the capillaries
systolic pressure
highest point of pressure on arterial walls when the ventricles contract
tachycardia
rapid heart rate (100-180 for adult)
tachypnea
increased respiratory rate
temperature
the difference between the amount of heat produced by the body and the amount of heat lost to the environment
vital signs
a person’s temperature, pulse, respiration, and blood pressure
pyrexia
fever
change-of-shift report
communication method used by nurses who are completing care for a patient to transmit patient info to nurses whoa re about to assume responsibility for continuing care; can be verbally or audiotaped
charting by exception (CBE)
shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes
collaborative pathway
abbreviated summary of key information taken from the more detailed case management plan
confer
to consult with someone to exchange ideas or to seek information, advice, or instruction
consultation
inviting another professional to evaluate the patient and make recommendations to you about his/her treatment
critical pathway
case mgmt plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; includes expected outcomes, list of interventions, and sequence/timing of those interventions
discharge summary
description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching/counseling the pt received, including referrals
documentation
the written or type legal record of all pertinent interactions with the patient - includes assessing, diagnosing, planning, implementing, and evaluating
electronic medical record (EMR)
computer-based records
flow sheet
documentation tools used to record routine aspects of nursing care
focus charting
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 problem/need. Narrative portion uses DAR (Data, Action, Response)
graphic sheet
form used to record specific patient variables such as T, P, R, B/P, I&O, weight, BM, and other patient characteristics
incident report
tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results or has the potential to result in harm to a patient, employee, or visitor
minimum data set
specific categories of information that use uniform definitions to create a common language among multiple healthcare data users
narrative notes
progress notes written by nurses in a source-oriented record that also address routine care, normal finding, and patient problems identified in the plan of care
nursing informatics
a specialty that integrates nursing science, computer science, and information science to manage and communicate data, info, and knowledge in nursing practice
OASIS
Outcome and Assessment Information Set - represents core items of a comprehensive assessment for an adult home care patient
patient record
compilation of a patient’s health information
personal health record (PHR)
contain the individual’s medical history, including diagnoses, symptoms, and medications. Some also include doctors’ notes, test results, CT images, insurance info, etc.
PIE charting
Problem, Intervention, Evaluation - does not develop a separate plan of care, it is incorporated into the progress notes
problem-oriented medical record (POMR)
organized around a patient’s problems rather than around sources of information
progress notes
notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes
SBAR communication
Situation Background Assessment Recommendation - the framework between members of the healthcare team about a patient’s care
SOAP format
Subjective data, Objective data, Assessment (the caregiver’s judgment about the situation), Plan
source-oriented record
a record in which each healthcare group keeps data on its own separate form (sections of record for nurses, physicians, lab, x-ray, etc.)
variance charting
documentation method in case mgmt that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate
referral
the process of sending or guiding the patient to another source for assistance
aerobic
bacteria that require oxygen to live and grow
anaerobic
bacteria that can live without oxygen
antibody
immunoglobin produced by the body in response to a specific antigen
antigen
foreign material capable of inducing a specific immune response
antimicrobial
antibacterial agent that kills bacteria or suppresses their growth
asepsis
absence of disease-producing microorganisms; using methods to prevent infection
bacteria
the most significant and most commonly observed infection-causing agents in healthcare institutions. Can be spherical, rod shaped, or corkscrew; can be gram-positive or gram-negative.
disinfection
process used to destroy microorganisms; destroys all pathogenic organisms except spores
endemic
a disease that occurs with predictability in one specific region or population
endogenous
infection in which the causative organism comes from microbial life the person himself harbors
exogenous
infection in which the causative organism is acquired from outside the host
fungi
plant-like organisms that also can cause infection
healthcare-associated infection (HAI)
an infection that was not present on admission to the hospital and develops during the course of treatment for other conditions (nosocomial)
host
animal/person on or within which microorganisms live
iatrogenic
infection that occurs as a result of a treatment or diagnostic procedure
infection
disease state resulting from pathogens in or on the body
isolation
protective procedure designed to prevent the transmission of specific microorganisms
medical asepsis
practices designed to reduce the number and transfer of pathogens (clean technique)
nosocomial
hospital-acquired infection
pathogen
disease-producing microorganism
personal protective equipment (PPE)
gloves, gown, masks, & protective eye gear designed to minimize or prevent exposure to infectious material
reservoir
natural habitat for growth & multiplication of microorganisms
standard precautions
CDC precautions used in the care of all patients regardless of their diagnosis or possible infection status
sterilization
the process by which all microorganisms, including spores, are destroyed
transmission-based precautions
CDC precautions used in patients known or suspected by be infected with pathogens that can be transmitted by airborne, droplet, or contact routes; used in addition to Standard Precautions
vector
nonhuman carriers, such as mosquitoes, ticks, and lice that transmit organisms from one host to another
virulence
ability to cause disease
virus
the smallest of all microorganisms; common cold, AIDS are caused by viruses.
asphyxiation
stoppage of breathing or the lack of air reaching the lungs; suffocation
bioterrorism
the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic
chemical terrorism
the deliberate release of a chemical compound that has the potential for harming people’s health
disaster
an emergency event of greater magnitude that requires the response of people outside the involved community
ground
conducting connection between a source of electricity and the earth
intimate partner violence (IPV)
domestic violence or battering between two people in a close relationship
nuclear terrorism
intentional dispersal of radioactive materials into the environment for the purpose of causing injury and death
poison control center
agency that handles poison exposure and provides poison prevention teaching to the general population
restraint
device used to limit movement or immobilize a client
safety event report
documentation describing any injury or potential for injury suffered by a patient in a healthcare agency
sentinel event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
active exercise
joint movement activated by the person
ankylosis
fixation or immobilization of a joint
atrophy
decrease in the size of a body structure
body mechanics
efficient use of the body as a machine and as a means of locomotion
cartilage
hard nonvascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx
contractures
permanently contracted state of a muscle
dangling
position in which the person sits on the edge of the bed with legs and feet dangling over the side of the bed
exercise
active exertion of muscles involving the contraction and relaxation of muscle groups
flaccidity
decreased muscle tone
footdrop
complication resulting from extended plantar flexion
isokinetic exercise
exercise involving muscle contractions with resistance varying at a constant rate
isometric exercise
exercise in which muscle tension occurs without a significant change in muscle strength
isotonic exercise
movement in which muscles shorten (contract) and move
ligaments
tough fibrous bands that bind joints together and connect bones and cartilage
negative nitrogen balance
condition resulting in muscle wasting and decreased physical energy for movement and work
neurons
nerve cells, which conduct impulses from one part of the body to another
orthopedics
the correction or prevention of disorders of body structures used in locomotion
osteoporosis
condition characterized by loss of calcium from bone tissue
paralysis
absence of strength secondary to nervous impairment
paresis
impaired muscle strength or weakness
passive exercise
manual or mechanical means of moving the joints
patient care ergonomics
practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care
range of motion (ROM)
complete extent of movement in which a joint is normally capable
spasticity
increased muscle tone
tendons
strong, flexible, inelastic fibrous bands that attach muscle to bone
tonus
normal, partially steady state of muscle contraction
alopecia
baldness
caries
cavities of the teeth
cerumen
wax in the external ear canals, consisting of a heavy oil and brown pigment
cheilosis
ulceration of the lips
gingivitis
inflammation of the gingivae or gums
glossitis
inflammation of the tongue
halitosis
offensive breath
pediculosis
infestation with lice
periodontitis
marked inflammation of the gums that also involved degeneration of the dental periosteum (tissues) and bone
plaque
invisible, destructive, bacterial film that builds up on teeth and eventually leads to the destruction of tooth enamel
stomatitis
inflammation of the oral mucosa
tartar
hard deposit on the teeth near the gum line formed by plaque buildup and dead bacteria
epidermis
the top layer, or outermost portion, of the skin
dermis
the second layer of skin; consists of a framework of elastic connective tissue
subcutaneous tissue
underlying layer of skin that anchors the skin layers to the underlying tissues of the body
wound
a break or disruption in the normal integrity of the skin and tissues
