Term
|
Definition
| Nursing role that encompasses keeping patients safe, communicating their needs, identifying side effects of treatment and finding better options, and helping them to understand their diseases and treatments so they can optimize self-care. |
|
|
Term
|
Definition
| True concern for the welfare of others. |
|
|
Term
|
Definition
| Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes. |
|
|
Term
|
Definition
| The right of patients to make decisions about their own health care. |
|
|
Term
|
Definition
| Assessment method in which a nurse examines the patient focused on a single system or clusters data related to that system together to identify issues |
|
|
Term
|
Definition
| An assessment that includes a complete health history and physical assessment; it is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or every 8 hours for patients in intensive care. |
|
|
Term
|
Definition
| Thinking that requires specific knowledge, skills, and experience and is purposeful and outcome-directed (results-oriented); driven by patient, family, and community needs; based on the nursing process, evidence-based thinking, and the scientific method; guided by professional standards and codes of ethics; and constantly re-evaluating, self-correcting, and striving to improve. |
|
|
Term
|
Definition
| The complex combination of knowledge, attitudes, and skills that a health care provider uses to deliver care that considers the total context of the patient's situation across cultural boundaries. |
|
|
Term
|
Definition
| Clustering of data that makes a judgment or statement about the patient's problem or condition. |
|
|
Term
|
Definition
| Gathering and clustering data to draw inferences and propose diagnoses. |
|
|
Term
|
Definition
An assessment that invilves a life-threatening or unstable situation and that focuses on
A-Airway (with cervical spine protection if injury suspected);
B-Breathing (rate and depth, use of accessory muscles);
C-Circulation (pulse rate and rhythm, skin color);
and D-Disability (level of consciousness, pupils, movement) |
|
|
Term
|
Definition
| Judgment of the effectiveness of nursing care in meeting the patient's goals and outcomes based upon the patient's response to intuition. |
|
|
Term
|
Definition
| Approach to patient care that minimizes intuition and personal experience and instead relies upon research findings and high-grade scientific support. |
|
|
Term
|
Definition
| An assessment based on the patient's issues that can occur in all health care settings; it usually involves one of two body systems and is smaller in scope than the comprehensive assessment but more in depth on the specific issue(s) |
|
|
Term
|
Definition
| An assessment that focuses on the functional patterns all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs. |
|
|
Term
|
Definition
| An assessment that organizes the collection of comprehensive physical data by proceeding through the entire body from head to toe. |
|
|
Term
|
Definition
| Model focused on the relationship between beliefs and actions, with the host (patient), agent (disease), and environment interacting. |
|
|
Term
|
Definition
| Model that views individuals as multidimensional and in interaction with interpersonal and physical environments as they pursue health, combining individual characteristics and experiences with behavior-specific cognition and affect, as well as with behavioral outcomes. |
|
|
Term
|
Definition
| Respect for patients, such as ensuring privacy and confidentiality. |
|
|
Term
|
Definition
| State in which patients experience objective signs and subjective symptoms of sickness, with subsequent disability. |
|
|
Term
|
Definition
| Providing honest information to patients, documenting care accurately, and reporting errors. |
|
|
Term
|
Definition
| Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes. |
|
|
Term
|
Definition
| Clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. |
|
|
Term
|
Definition
| Measurable findings from the health assessment, usually gathered in the physical examination. |
|
|
Term
|
Definition
| More specific than goals, these are the realistic and measurable desired consequences of nursing interventions. |
|
|
Term
|
Definition
| Determining resources, targeting nursing interventions, and writing the plan of care. |
|
|
Term
|
Definition
| An important professional nursing skill by which nurses organize activities and issues by focusing on the most important and immediate concerns first. Priorities depend upon the acuity of the situation. |
|
|
Term
|
Definition
| Working to ensure for patients equal treatment and access to quality health care. |
|
|
Term
|
Definition
| Findings from the health assessment that are based on patient experiences and perceptions. They are usually revealed during the interview and health history taking. |
|
|
Term
|
Definition
| Process by which people maintain balance and direction in the most favorable environment. |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| head, eyes, ears, nose, throat |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| pupils equal, round, reactive to light and accommodation |
|
|
Term
|
Definition
|
|
Term
|
Definition
| point of maximal impulse (apical heart) |
|
|
Term
|
Definition
| paroxysmal nocturnal dyspnea |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| single, married, widowed, divorced |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| temperature, pulse, respiration |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| The ability to focus on patients and their perspectives. |
|
|
Term
|
Definition
| A therapeutic communication technique that nurses use when a patient's word choice or ideas are unclear to better understand the meaning. For example, the nurse states, "tell me what you mean by..." Clarification prompts patients to identify other facts or give more information so that the nurse better understands. |
|
|
Term
| Closed-ended (direct) questions |
|
Definition
| Questions that yield "yes" or "no" responses and are focused on obtaining facts. An example would be, "do you have a family history of heart disease?" |
|
|
Term
|
Definition
| The code of conduct and good manners by which those engaged in communication show respect for others. |
|
|
Term
|
Definition
| The ability to perceive, reason, and communicate understanding of another person's feelings without criticism. It is being able to see and feel the situation from the patient's perspective, not the nurse's. |
|
|
Term
|
Definition
| A technique that assists patients to more completely describe problems. these responses encourage patients to say more and continue the conversation. They show the patients that the nurse is interested. |
|
|
Term
|
Definition
| A therapeutic communication technique used when patients are straying from a topic and need redirection. |
|
|
Term
| Intercultural communication |
|
Definition
| The sender of an intended message belongs to one culture, while the receiver is from another. Cultural differences may exist related to group or ethnicity, region, age, degree of acculturation into Western society, or a combination of these factors. |
|
|
Term
|
Definition
| Questions that require patients to give more than "yes" or "no" answers. They are broad and provide responses in the patient's own words. |
|
|
Term
|
Definition
| Similar to restatement; however, instead of simply restating comments, the nurse summarizes the main themes of communication. The conversation may be longer, in which a patient discusses several elements related to a topic. |
|
|
Term
|
Definition
| A therapeutic communication technique by which the nurse makes a simple statement, usually using the words of the patient, to prompt the patient to elaborate. Restatement provides an opportunity for patients to further understand their communication. |
|
|
Term
| Sexual boundary violation |
|
Definition
| The clearest example of unprofessional involvement. Sexual contact is never acceptable within the therapeutic nurse-patient relationship. |
|
|
Term
|
Definition
| Purposefully not speaking during an interview to allow patients time to gather their thoughts and provide accurate answers or to communicate nonverbal concern. Silence also gives patients a chance to decide how much information to disclose. |
|
|
Term
|
Definition
| Used at the end of the interview, during the closure phase, when the nurse reviews and condenses important information into two or three of the most important findings. Doing so helps ensure that the nurse has identified important information and lets the patient know that he or she has been heard accurately. |
|
|
Term
| Therapeutic communication |
|
Definition
| A basic tool that the nurse uses in the caring relationship with patients. In therapeutic communication, the interaction focuses on the patient and the patient's concerns. The nurse assists patients to work through feelings and explore options related to the situation, outcomes, and treatments. |
|
|
Term
| Activites of daily living |
|
Definition
| Self-care activities such as eating, dressing, and grooming. |
|
|
Term
| Functional health patterns |
|
Definition
| Areas assessed by nurses that are based on groupings that focus on one specific segment and how the effects of health or illness influence a patient's quality of life. |
|
|
Term
|
Definition
| Information gathered directly from the individual patient. |
|
|
Term
|
Definition
| A historian provides information consistent with existing records and comprehensive in scope |
|
|
Term
|
Definition
| A series of questions about all body systems that helps to reveal concerns or problems as part of a comprehensive health assessment. |
|
|
Term
|
Definition
| Data gathered from the patient's chart and family members. |
|
|
Term
|
Definition
| Objective information that the nurse assesses during the physical examination. |
|
|
Term
|
Definition
| Data based on the signs and symptoms that the patient reports; they may not be perceived by observers. |
|
|
Term
|
Definition
| Subjective sensations or feelings of patients. |
|
|
Term
|
Definition
| One of the techniques used for conducting a physical assessment by which the nurse listens for movements of air or fluid in the body. |
|
|
Term
|
Definition
| A tone of a sound during physical assessment that is high in pitch, sounds like a thud, and is heard over the liver. |
|
|
Term
|
Definition
| A tone of sound during physical assessment that is high in pitch, sounds dull, and is head over bone. |
|
|
Term
|
Definition
| Practices that include the use of alcohol-based hand rubs, hand washing, and use of gloves. |
|
|
Term
|
Definition
| A tone of a sound during physical assessment that is very loud, boom-like in quality, of long duration, and head over emphysematous lungs. |
|
|
Term
|
Definition
| A technique used in a physical assessment by which the nurse observes the patient for general appearance and any specific details related to the body system, region , or condition under examination. |
|
|
Term
|
Definition
| A handheld system of lenses, lights, and mirrors that enables visualization of the interior structures of the eye. |
|
|
Term
|
Definition
| An instrument that directs light into the ear to visualize the ear canal and tympanic membrane. |
|
|
Term
|
Definition
| An assessment technique by which the nurse uses the hands to feel the firmness of body parts, such as the abdomen. |
|
|
Term
|
Definition
| An assessment technique by which the nurse uses tapping motions with the hands to produce sounds that indicate solid or air-filled spaces over the lungs and other areas. |
|
|
Term
|
Definition
| A tone of a sound during physical assessment that is very loud, hollow in quality, of long duration, and head over healthy lungs. |
|
|
Term
|
Definition
| A set of guidelines the Centers for Disease Control and Prevention that exist to help prevent disease transmission during contact with nonintact skin, mucous membranes, body substances, and bloodborne contacts. |
|
|
Term
|
Definition
| A piece of equipment used with two body systems: to determine vibration sense in the neuromuscular system and to determine conductive versus sensorineural hearing loss in the ears. |
|
|
Term
|
Definition
| Refers to the membrane that separates the outer ear from the middle ear. It can also describe a loud, high-pitched, drum-like sound of moderate duration heard during the physical assessment. |
|
|
Term
|
Definition
| Review of a health care facility by an agency or outside group to determine whether that facility is providing and documenting certain standards of care. |
|
|
Term
|
Definition
| Waiting until the end of shift or until all patients have been assessed to document findings from all of them. |
|
|
Term
|
Definition
| Use of predetermined standards and norms to record only significant assessment data. |
|
|
Term
|
Definition
| Keeping information private. |
|
|
Term
|
Definition
| Efficient and standardized form that assembles the collected information in a way that permits easy comparison among assessment data to detect trends or a sudden change in status. |
|
|
Term
|
Definition
| Transfer of care for a patient from one health provider to another. |
|
|
Term
| Point of care documentation |
|
Definition
| Occurs when nurses document assessment information as they gather it, often using a portable computer. |
|
|
Term
|
Definition
| Occurs at handoffs, during patient rounds, during patient and family care conferences, and when calling or text-paging a provider to report a change in status or provide requested information. |
|
|
Term
|
Definition
| Computerized provider order entry |
|
|
Term
|
Definition
| the health insurance portability and accountability act |
|
|
Term
|
Definition
| outcome and assessment information set |
|
|
Term
|
Definition
| situation, background, assessment, recommendation |
|
|
Term
|
Definition
| subjective, objective, assessment, plan |
|
|
