Fundamental Concepts & Skills

Front 1

affective domain

Back 1

The material is presented in a way that appeals to the learner's beliefs, feelings, and values

Front 2

Auditory Learning

Back 2

Aurally, through what they hear

Front 3

Behavioral Objective

Back 3

represent the desired changes or additions to current behaviors and attitudes

Front 4

Cognitive Domain

Back 4

The learner takes in and processes information by listening to or reading the material

Front 5

feedback

Back 5

return of information about the process

Front 6

Kinesthetic Learning

Back 6

By actually performing a task or handling items

Front 7

Psychomotor domain

Back 7

The learner processes the information by performing an action or carrying our a task

Front 8

charting

Back 8

Is used to track the application of the nursing process

Front 9

Case management system charting

Back 9

which tracks variances from the clinical pathway

Front 10

Charting by exception

Back 10

Which focuses on deviations from pre-defined norms using preset protocols and standards of care

Front 11

Computer-assisted charting

Back 11

Where data are input to the computer.

Front 12

Computerized provider order entry (CPOE)

Back 12

Provides for efficiency of work flow because when orders are entered into the computer there is automatic routing to the appropriate clinical areas for action

Front 13

focus charting

Back 13

which centers on the patient from a positive perspective.

Front 14

Medical records (chart)

Back 14

Contains all orders, tests, treatment, and care that occurred during the time the person was under the care of the health care provider

Front 15

PIE charting

Back 15

P-problem
I-enterventions
E-evaluation
this type of charting follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses progress notes

Front 16

Problem oriented medical record (POMR) charting

Back 16

Which focuses on the problems experienced by the patient as a result of being ill or on the defined nursing diagnoses reflecting those problems

Front 17

Protocols

Back 17

Standard procedures

Front 18

Source-oriented (narrative) charting

Back 18

which focuses on the patient's disease

Front 19

Automony

Back 19

Control over personal decisions

Front 20

Beneficence

Back 20

Doing good

Front 21

Beneficent paternalism

Back 21

Health care provider making decisions for the patient based on "I know what's best for you." discount patient autonomy

Front 22

ethics

Back 22

Rules or principles that govern correct conduct

Front 23

fidelity

Back 23

in nursing to be faithful to the charge of acting in the patient's best interest when the capacity to make free choice is no longer available

Front 24

justice

Back 24

Giving patients their due and treating them fairly

Front 25

Morals

Back 25

Ethical habits of a person

Front 26

Nonmaleficence

Back 26

First, DO NO HARM

Front 27

Nursing ethics

Back 27

System of principles governing conduct of nurses

Front 28

Privacy

Back 28

Both a legal and ethical issue. Patient's right to choose what is done to his/her body, based on personal eliefs, feelings, and attitude

Front 29

Values

Back 29

Assigned to an idea or action. Freely chosen and affected by age, experience, and maturity.

Front 30

Cues

Back 30

Are pieces of data or information that influence decisions

Front 31

Data

Back 31

Pieces of information on a specific topic

Front 32

Database

Back 32

All the information gathered about the patient.

Front 33

Defining Characteristics

Back 33

Are those characteristics that must be present for a particular nursing diagnosis to be appropriate for that patient?

Front 34

Etiologic factors

Back 34

Are the causes of the problem

Front 35

Expected outcomes

Back 35

Is a specific statement of the goal the patient is expected to achieve as a result of nursing intervention

Front 36

Goal

Back 36

Is a broad idea of what is to be achieved through nursing interventions

Front 37

Inferences

Back 37

Conclusion made based on observed data

Front 38

Interview

Back 38

Conversation where facts are obtained

Front 39

Nursing diagnoses

Back 39

Indicates the patient’s actual health status or the risk of a problem developing the causive or related factors and specific defining characteristics

Front 40

Objective data

Back 40

Information obtained through senses and hands on physical examination

Front 41

Signs

Back 41

Are abnormalities that can be verified by repeat examination

Front 42

Subjective data

Back 42

Data obtained from the patient verbally. What the patient says.

Front 43

Symptoms

Back 43

Are data the patient has said are occurring that cannot be verified by examination

Front 44

Chart

Back 44

Document

Front 45

Clinical pathway/care map

Back 45

Is a step-by-step approach to the total care of the patient.

Front 46

Continuous quality improvement

Back 46

Process of continually evaluate nursing care to identify specific areas that need changes for improvement

Front 47

Dependent Nursing action

Back 47

Action requiring a physician order.

Front 48

Documentation

Back 48

The recording of pertinent data on the clinical record

Front 49

Evaluation

Back 49

Judgment of the effectiveness of the intervention or plan

Front 50

Implementation

Back 50

Performing an intervention and assessing the response

Front 51

Independent Nursing Action

Back 51

An action that does not require a physician’s order, but does require critical thinking.