TERMS Flashcards
Reciprocity
allows a nurse to be endorsed as an RN by another state outside of the one they were originally licensed
Mindfulness
the capacity to intentionally bring awareness to present-moment experience with an attitude of openness and curiosity
Morbidity
how frequently a disease occurs
Mortality
numbers of deaths resulting from a disease
Remission
present, but person does not experience symptoms
Exacerbation
symptoms of the disease reappear
Health equity
attainment of the highest level of health for all people
Social determinants of health
conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks
Vulnerable populations
racial and ethnic minorities, those living in poverty, women, children, older adults, rural and inner-city residents, and people with disabilities and special health care needs
Health promotion -
behavior of a person who is motivated by a personal desire to increase well-being and health potential
Nuclear family
aka traditional family, composed of two parents and their children
Extended family
relatives such as aunts, uncles, and grandparents
Blended family
parents who bring unrelated children from previous relationships together to form a new family
applied research
is also called practical research) is designed to directly influence or imiprove clinical practice.
basic research
sometimes called pure or laboratory research) is is designed to generate and refine theory; the findings are often not directly useful in practice.
concept
like ideas, are abstract impressions organized into symbols of reality. Concepts describe objects, properties, and events and relationship among them.
Systematic review
summarize findings from multiple studies of a specific clinical practice question or topic and recommed practice changes and future directions for research.
Charting by exception
shorthand documentation method that makes use of well-defined standards of practice; only significant findings or “exceptions” to these standards are documented in narrative notes.
Confer
consult with someone to exchange ideas or to seek information, advice, or instructions.
Critical/collaborative pathway
specifies the care plan linked to expected outcomes along a timeline.
Discharge summary
a summary of the reason for the patient’s treatment, significant findings, procedures performed and treatments rendered, patient’s condition on discharge or transfer, and any specific pertinent instructions given to the patient and family.
Flow sheet
documentation tools used to efficiently record routine aspects of nursing care.
Focus charting
brings the focus of care back to the patient and the patient’s concerns. A focus column is used that incorporates many aspects of a patient and patient care.
Graphic record
a form used to record specific patient variables such as pulse, RR, BP readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.
Health information exchange (HIE)
an electronic platform that allows health care providers and patients to appropriately access and securely share a patient’s vital medical information, improving speed, quality, safety, and cost of patient care.
Incident Report (aka variance report)
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.
ISBAR communication
a method of communication between members of the health care team about a patient’s condition. I-identity/introduction. S-Situation. B-Background. A-Assessment. R-Recommendation. It allows for an easy and focused way to set expectations for what and will be communicated, and how.
Minimum data set
core set of screening, clinical, and functional status elements that form the foundation of the comprehensive assessment of all residents in long term care facilities certified to participate in Medicare or Medicaid.
Narrative notes
Progress notes written by nurses in a source-oriented record and address routine care, normal findings, and patient problems identified in the care plan.
Occurrence charting (aka variance charting)
when a patient fails to meet an unexpected outcome or a planned intervention is not implemented in the case management model, the variance from the plan is documented; the unexpected event, the cause of event, actions taken in response to the event and discharge planning when appropriate.
Outcome and assessment information set (OASIS)
a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)
PIE charting
Problem, Intervention, Evaluation. In this system, a patient assessment is performed and documented at the beginning of each shift using preprinted fill-in-the-blank assessment forms. PIE charting eliminates the need for the traditional care plan because the ongoing plan of care is incorporated into daily documentation.
Problem oriented medical record (POMR)
paper record used in some health facilities that provides a quick and structured acquisition of the patient’s history. POMR focuses on patient’s problems rather than around sources of information.
Purposeful rounding
proactive, systematic, nurse driven, evidence-based intervention that helps nurses anticipate and address patient needs.
Read-back
when a recipient reads back the message as he or she heard and confirms its accuracy.
Source oriented record
a paper format in which each health care group keeps data on its own separate form.
clinical judgment
refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes
clinical reasoning
a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking
standards for critical thinking
clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair
Cue
significant information that is helpful in making decisions
Data Cluster:
grouping of patient data or cues that point to the existence of a patient health problem
Diagnostic Error:
failure to detect an actual unhealthy behavior or condition
Health Problem
condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted
Patient outcome
expected conclusion to a patient health problem or expected conclusion to patient’s health expectation
Expected outcomes
refer to more specific, measurable criteria used to evaluate the extent to which a goal has been met
Nursing Outcomes Classification (NOC)
comprehensive standardized language used to describe patient outcomes that are responsive to nursing intervention
Nursing intervention
treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes
Nurse-initiated intervention
autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes\
Physician-initiated interventions
response by physician to a medical diagnosis that is carried out by a nurse in response to a doctor’s order
Collaborative interventions
treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants
Clinical pathways (critical pathways, CareMaps)
tools used in case management to communicate the standardized, interdisciplinary care plan for patients
Clinical inquiry
Ongoing process of questioning and evaluating practice and evaluating practice and advancing informed practice.
Direct Care Intervention
Treatment performed through change and assessing the interaction with the patient.
Indirect Care Intervention
Treatment performed away from the patient but on behalf of a patient or group of patients.
Nursing Intervention protocols
Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes, there are nurse initiated, physician initiated, and collaborative interventions.
Standing Orders
Document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities.
Unlicensed assistive personnel (UAPs)-
Individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse.
Criteria
measurable qualities, attributes, or characteristics that identify skills, knowledge, or health states
Standards
levels of performance accepted by and expected nursing staff or other health team members established by authority, custom, or consent
Evaluative statement
a judgement summarizing the findings from the data that’s been collected and interpreted to determine patient outcome achievement
Performance improvement
steps crucial in improvement: discovering a problem; planning a strategy using indicators; implementing change; assessing the change — if outcome not met, plan a new strategy
Structure evaluation
focuses on the environment on which care is provided, including the physical facilities and equipment, organizational characteristics, policies, and procedures; fiscal resources; and personnel resources
Process evaluation
nature and sequence of activities carried out by nurses implementing the nursing process
Outcome evaluation
focuses on measurable changes in the health status of the patient, or the end results of nursing care
National Database of Nursing Quality Indicators (NDNQI)
promote and facilitate the standardization of information submitted by hospitals across the US on nursing quality and patient outcomes
Concurrent evaluation
conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met
Retrospective evaluation
use post discharge questionnaires, patient interviews (by phone or face to face), or chart review to collect data
Aerobic
Bacteria requiring oxygen to live and grow
Anaerobic
Bacteria that can live without oxygen
Bundles
A structured way of improving the processes of care and patient outcomes. A small straight forward set of evidence-based practices that waiver form collectively and reliably have been proven to improve patient outcomes
Disinfection
Destroys all pathogenic organisms except spores
Endemic
A disease that occurs with predictability in one specific region or population
Endogenous
When the causative organism comes from microbial life harbored inside of the person
Exogenous
When the causative organism is acquired from other people
Iatrogenic
An infection that results from a treatment or diagnostic procedure
Vector
A living creature that transmits an infectious agent to a human such, usually an insect
Alopecia
a partial or complete, local or generalized, absence or loss of hair
Cheilosis
And alteration and dry scaling of the lips with fishers at the angles of the mouth
active exercise
Joint movement activated by the person
contractures
Permanently contracted state of muscle
flaccidity
Decreased muscle tone; synonym for hypotonicity
foot drop
Complication resulting from extended plantar flexion
paresis
Impaired muscle strength or weakness
passive exercise-
Manual or mechanical means of moving the joints (Movement of the body, usually of the limbs, without effort by the patient.)
patient care ergonomics
practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care
spasticity
Increased muscle tone
tonus
Normal, partially steady-state of muscle contraction
abscess
is a collection of infected fluid that has not drained
Bandages and binders
are used to secure dressings, apply pressure and support the wound. Bandages are strips of cloth, gauze or elasticized material used to wrap a body part.
Biofilm
is a thick group of microorganisms.
Dehiscence
is the partial or total separation of wound layers as result of excessive stress on wound that are not healed.
Desiccation
dehydration) is the process of drying up. Cells dehydrate and die in a dry environment- is one of the factor affecting wound healing.
Epithelialization
is epithelial cell migration to the wound bed.
Eschar
is tan, brown, or dry black leathery hardened dead tissue that fall off from healthy skin. (need to removed to identify stage 3 or 4). Slough is yellow, tan, gray, green or brown dead tissue.
Evisceration
is the most serious complication of dehiscence. It occurs primarily with abdominal incisions.
Exudate
is fluid that leak out of blood vessels into nearby tissue (in homostasis- 1st phase of wound healing)
Fistula
is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another
Friction
occurs when 2 surfaces rub against each other, the injury which resembles an abrasion also can damage superficial blood vessels directly under the skin.
Granulation tissue
is a thin layer of epithelial cell comes across the wound, forms the foundation for scar tissue development
Ischemia
is deficiency of blood in a particular area
Maceration
overhydration) is the softening and breakdown of skin, results from prolonged exposure to moisture (related to urinary and fecal incontinence) – one of the factor affecting wound healing.
Negative pressure wound therapy (NPWT)
promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and removal of excess wound fluid, while providing a moist wound healing environment.
Pressure injury
localize damage to the skin and underlying tissue that usually occurs over a boby prominence or is related to the use of a medical or other device
Pressure ulcer
was replaced by pressure injury (2016) to have a better understanding of the early stage of pressure injury.
Purulent drainage
is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteris. It is thinkc, often has a musty or foul odor and varies in color (dark yellow or green) depending on the causative organism.
Sanguineous drainage
consists of large numbers of red blood cells and looks like blood. Bright -red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicate older bleeding.
Serosanguineous drainage
is a mixture of serum and red blood cells. It is light pink to blood tinged.
Serous drainage (clear and watery)
is composed primarily of the clear, serous portion of the blood and from serous membranes.
Shear
results when one layer of tissue slides over another layer (When moving pt on bed if pt is pulled rather than lifted, risk from injury from shearing forces.)
Sinus tract
is an abnormal pathway in a wound, a cavity or channel underneath the wound that has the potential for infection.
