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
