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436 Cards in this Set
- Front
- Back
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Accountability
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being responsible for one's actions and accepting the consequences of one's behavior
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Action stage
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occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones; this stage requires the greatest commitment of time and energy
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Active euthanasia
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actions that directly bring about the client's death with or without consent
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Activities
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the specific nursing actions needed to carry out the interventions (or nursing orders)
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Actual loss
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can be identified by others and can arise either in response to or in anticipation of a situation
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Acute illness
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typically characterized by severe symptoms of relatively short duration
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acute pain
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Pain that lasts only through the expected recovery period from illness, injury, or surgery, whether it has a sudden or slow onset and regardless of the intensity.
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Adherence
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the extent to which an individual’s behavior (for example, taking medications, following diets, or making lifestyle changes) coincides with medical or health advice
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Advance health care directive
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a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences
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adventitious sounds
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Added sounds superimposed on normal breath sounds and often indicative of underlying airway problems or diseases of the cardiovascular or respiratory systems.
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Advocate
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individual who pleads the cause of another or argues or plead for a cause or proposal
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Algor mortis
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the gradual decrease of the body's temperature after death
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Allen test
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Test used to determine patency of the radial and ulnar arteries.
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anabolism
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A condition that occurs when the intake of protein and calories exceeds the nitrogen loss.
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angle of Louis
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(Sternal angle) A horizontal ridge formed at the point where the manubrium joins the body of the sternum.
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angular stomatitis
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A clinical finding of poor nutrition, cracks at the corner of the mouth.
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anthropometrics
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Any scientific measurement of the body.
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Anticipatory grief
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grief experienced in advance of the event
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Anticipatory loss
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the experience of loss before the loss actually occurs
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arterial aneurysm
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A bulging or dilation caused by a weakness in the wall of an artery.
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arterial insufficiency
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Inadequate circulation in the arterial system, usually due to the buildup of fatty plaque or calcification of the arterial wall resulting in diminished pulses; cool, shiny skin; absence of hair on toes; pallor on elevation, red color when dependent; and deep muscle pain, usually in the calf or lower leg aggravated by activity and elevation of the limb.
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arteries
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Part of the peripheral vascular system that receive oxygen-rich blood from the heart and carry it to the organs and tissues of the body.
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Asphyxiation
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lack of oxygen due to interrupted breathing
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Assessing
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the process of collecting, organizing, validating, and recording data (information) about a client’s health status
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Assignment
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a downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another
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Assisted suicide
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a form of active euthanasia in which clients are given the means to kill themselves
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Atrioventricular Valves
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Valves that separate the atria from the ventricles.
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atrophic papillae
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A clinical finding of poor nutritional health.
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attending
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Giving full time and attention to verbal and non-verbal messages.
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Attentive listening
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listening actively, using all the senses, as opposed to listening passively with just the ear
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Attitudes
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mental stance that is composed of many different beliefs; usually involving a positive or negative judgment toward a person, object, or idea
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auscultation
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The skill of listening to the sounds produced by the body.
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Autonomy
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the state of being independent and self-directed without outside control, to make one's own decisions
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Autonomy
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the state of being independent and self-directed without outside control, to make one's own decisions
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Autopsy
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an examination of the body after death to determine the cause of death and to learn more about a disease process
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Beliefs
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interpretations or conclusions that one accepts as true
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Beneficence
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the moral obligation to do good or to implement actions that benefit clients and their support persons
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Bereavement
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a subjective response of a person who has experienced the loss of a significant other through death
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Bioethics
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ethical rules or principles that govern right conduct concerning life
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blood pressure
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Pressure caused by waves of blood as it ebbs and flows within the systemic arteries.
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bronchial sounds
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Loud, high-pitched sounds heard next to the trachea and are longer on exhalation.
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bronchophony
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Auscultation of voice sounds, patient says "ninety-nine" and normal lung sound will be muffled.
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bronchovesicular sounds
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Sounds that are medium in loudness and pitch, heard between the scapula, posteriorly and next to the sternum, and anteriorly upon inhalation and exhalation.
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Bruit
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A loud blowing sound, an abnormal finding, most often associated with a narrowing or stricture of the carotid artery usually associated with atherosclerotic plaque.
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bruit
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An obstruction causing turbulence, indicated by a swishing sound.
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Bundle Branches
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Expressways of conducting fibers that spread the electrical current through the ventricular myocardial tissue.
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Bundle of His Atrioventricular Node
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Nodes that are intricately connected and function to receive the current that has finished spreading throughout the atria.
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Burn
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results from excessive exposure to thermal, chemical, electric, or radioactive agents
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capillaries
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The smallest vessels of the circulatory system that exchange gases and nutrients between the arterial and venous systems.
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Carbon monoxide
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an odorless, colorless, tasteless gas that is very toxic
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Cardiac arrest
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the cessation of heart function
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Cardiac Conduction System
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The heart's conduction system which can initiate an electrical charge and transmit that charge via cardiac muscle fibers throughout the myocardial tissue.
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Cardiac Cycle
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The events of one complete heartbeat, the contraction and relaxation of the atria and ventricles.
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Cardiac output
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The amount of blood ejected from the left ventricle over 1 minute.
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Caregiver
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arrole that has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity
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Caring
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an essential aspect of nursing
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Case management
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a method for delivering nursing care in which the nurse is responsible for a case load of clients across the health care continuum
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Case manager
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a nurse who works with the multidisciplinary health care team to measure the effectiveness of the case management plan and monitor outcomes
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catabolism
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A condition that occurs when there is a negative nitrogen balance.
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cephalocaudal
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Head to toe, direction.
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Cephalocaudal
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proceeding in the direction from head to toe
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Cerebral death
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the higher brain center or cerebral cortex is irreversibly destroyed
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Change agent
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a person (or group) who initiates changes or who assists others in making modifications in themselves or in the system
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Change-of-shift report
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a report given to nurses on the next shift
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Chart
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a formal, legal document that provides evidence of a client’s care
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Charting
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the process of making an entry on a client record
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Charting by exception (CBE)
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a documentation system in which only significant findings or exceptions to norms are recorded
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cheilosis
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Inflamation of mouth.
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Chemical restraints
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medications used to control socially disruptive behavior
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Chronic illness
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illness that lasts for an extended period of time, usually greater than 6 months
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chronic pain
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Pain that is prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning.
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Clara Barton
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a schoolteacher who volunteered as a nurse during the Civil War. Most notably, she organized the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882
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Client
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a person who engages the advice or services of another person who is qualified to provide this service
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Client advocate
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an individual who pleads the cause of clients’ rights
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Client advocate
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an individual who pleads the cause of clients’ rights
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Client record
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see Chart
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Closed awareness
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a type of awareness in which the client is unaware of impending death
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Closed questions
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restrictive question requiring only a short answer
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clubbing
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Flattening of the angle of the nail and enlargement of the tips of the fingers is a sign of oxygen deprivation in the extremities.
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Code of ethics
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a formal statement of a group's ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions
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Cognitive skills
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(intellectual skills) that include problem solving, decision making, critical thinking, and creativity
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Coinsurance
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an insurance plan where the client pays a percentage of the payment and some other group (eg, employer, government) pays the additional percentage
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Collaborative care plan
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see Critical pathway
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Collaborative interventions
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actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians
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Comfort
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a renewal, an amplification of power or sense of control, an invigorating influence, a positive mind-set, and a readiness for action
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Comforting
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a group of nursing interventions based on clients' cues of distress, with the goal of achieving client comfort
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Communication
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a two-way process involving the sending and receiving of messages
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communication
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The exchange of information between individuals.
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Communicator
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nurses identify client problems and then communicate these verbally or in writing to other members of the health team
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concreteness
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Speaking to the client in specific terms rather than in vague generalities.
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Congruent communication
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the verbal and nonverbal aspects of the message match
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Consequence-based (teleological) theories
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the ethics of judging whether an action is moral
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Consumer
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an individual, a group of people, or a community that uses a service or commodity
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Contemplation stage
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the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future
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Coroner
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a public official, not necessarily a physician, appointed or elected to inquire into the causes of death
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Counseling
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the process of helping a client to recognize and cope with stressful psychologic or social problems, to develop improved interpersonal relationships, and to promote personal growth
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Covert data (symptoms, subjective data)
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information (data) apparent only to the person affected that can be described or verified only by that person
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Creativity
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thinking that results in the development of new ideas and products
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Critical analysis
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a set of questions one can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas
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Critical pathway
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multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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Critical pathways
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multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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Critical thinking
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a cognitive process that includes creativity, problem solving, and decision making
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Cues
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any piece of information or data that influences decisions
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cues
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Bits of information that hint at the possibility of a health problem.
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cutaneous pain
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Pain that originates in the skin or subcutaneous tissue.
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Data
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information
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Database
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all information about a client, includes nursing health history and physical assessment, physician's history and physical examination, laboratory and diagnostic test results
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database
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Subjective and objective data gathered regarding client wellness, growth and development, culture, and psychosocial considerations.
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Decision making
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the process of establishing criteria by which alternative courses of action are developed and selected
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Decode
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to relate the message perceived to the receiver’s storehouse of knowledge and experience and to sort out the meaning of the message
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Deductive reasoning
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making specific observations from a generalization
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deep somatic pain
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Diffuse pain that arises from ligaments, tendons, bones, blood vessels, and nerves, tends to last longer than cutaneous pain.
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Defining characteristics
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client signs and symptoms that must be present to validate a nursing diagnosis
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Delegation
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the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome
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Demography
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the study of population, including statistics about distribution by age and place of residence, mortality, and morbidity
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Dependent functions
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with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out
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Dependent interventions
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hose activities carried out on the order of the physician, under the physician’s supervision, or according to specified routines
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Diagnosis
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a statement or conclusion concerning the nature of some phenomenon
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Diagnosis-related groups (DRGs)
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a Medicare payments system to hospitals and physicians which establishes fees according to diagnosis
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Diagnostic labels
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title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association’s (NANDA) standardized taxonomy of terms
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Diagnostic-related groups (DRGs)
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a Medicare payments system to hospitals and physicians which establishes fees according to diagnosis
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Diastole
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The phase of ventricular relaxation in which the ventricles relax and are filled as the atria contract.
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diet recall
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24-hour recall, patient verbally recalls all food, beverages, and nutritional supplements or products consumed in a set 24-hour period".
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Directive interview
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a highly structured interview that uses closed questions to elicit specific information
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Discharge planning
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the process of anticipating and planning for client needs after discharge
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Discussion
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an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
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Disease
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an alteration in body function resulting in a reduction of capacities or shortening of the normal life span
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Documenting
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see Charting or Recording
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Do-not-resuscitate order (DNR)
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a physician’s order that specifies no effort be made to resuscitate the client with terminal or irreversible illness in the event of a respiratory or cardiac arrest.
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dullness
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A high-pitched tone that is soft and of short duration.
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dullness
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The level of the diaphragm during quiet respiration.
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Dysfunctional grief
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the state in which an individual or group experiences prolonged, unresolved grief and engages in detrimental activities
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dyspnea
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A change in normal breathing pattern, producing shortness of breath or difficulty in breathing.
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edema
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Increased accumulation of fluid which could indicate an obstruction of the lymphatic system.
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egophony
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Ausculation of voice sounds, patient says "E", normal lungs sound like "eeeeee".
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Electric shock
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occurs when a current travels through the body to the ground rather than through electric wiring, or from static electricity that builds up on the body
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Electrocardiogram (EKG)
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Electrical representations of the cardiac cycle are documented by deflections on recording paper.
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empathy
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"The capacity to respond to another’s feelings and experiences as if they were your own” (Cormier, Cormier, & Weiser, 1984, p. 22)
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Empathy
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the ability to discriminate what the other person's world is like and to communicate to the other this understanding in a way that shows that the helper understands the client's feelings and the behavior and experience underlying these feelings
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Encoding
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involves the selection of specific signs or symbols (codes) to transmit the message, such as which language and words to use, how to arrange the words, and what tone of voice and gestures to use
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encoding
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The process of formulating a message for transmission to another person.
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Endocardium
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The innermost layer of the heart, a smooth layer that provides an inner lining for the chambers of the heart.
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End-of-life care
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care provided in the final weeks before death
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epitrochlear node
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Node located on the medial surface of the arm above the elbow that drains the ulnar surface of the forearm and the third, fourth, and fifth digits.
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Ethics
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the rules or principles that govern right conduct
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Etiology
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the causal relationship between a problem and its related or risk factors
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Etiology
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the causal relationship between a problem and its related or risk factors
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eupnea
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The regular, even-depth, rhythmic pattern of inspiration and expiration; normal breathing.
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Euthanasia
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the act of painlessly putting to death persons suffering from incurable or distressing disease
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Evaluating
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a planned ongoing, purposeful activity in which clients and health care professionals
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Evaluation statement
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a statement that consists of two parts: a conclusion and supporting data
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Exacerbation
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the period during a chronic illness when symptoms reappear after remission
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Fabiola
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a wealthy Roman matron – viewed by some as the patron saint of early nursing who used her position and wealth to establish hospitals for the sick
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false reassurance
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The client is assured of a positive outcome with no basis for believing in it.
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Feedback
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the response or message that the receiver returns to the sender during communication
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Fidelity
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a moral principle which obligates the individual to be faithful to agreements and responsibilities one has undertaken
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fifth vital sign
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Pain assessment.
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flag sign
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Dyspigmentation of mouth.
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flatness
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A high-pitched tone, very soft, and of very short duration.
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Florence Nightingale
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considered the founder of modern nursing, she was influential in developing nursing education, practice, and administration
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Flowsheet
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a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form
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Focus charting
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a method of charting that uses key words or foci to describe what is happening to the client
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focused interview
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Interview used to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur, guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses.
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food frequency questionnaire
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A questionnaire that assesses intake of a variety of food groups on a daily, weekly, or longer basis.
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food security
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A parameter used in nutritional assessment, free access to adequate and safe food.
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Formal nursing care plan
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a written or computerized guide that organizes information about the client’s care
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fremitus
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The palpable vibration on the chest wall when the client speaks.
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fremitus
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Vibratory tremors felt through the chest wall.
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functional assessment
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An observation to gather data while the client is performing common or routine activities.
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general survey
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Initial impressions based on what is seen, heard, or smelled during the initial phase of assessment.
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genogram
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A pictorial representation of family relationships and medical history.
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genuineness
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The ability to present oneself honestly and spontaneously.
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glossitis
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A clinical finding of poor nutrition, glands are smooth, beefy red or magenta.
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Goals/desired outcomes
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a part of a care plan that describes in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
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Governance
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the establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, self-discipline, working conditions, and professional affairs
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Grief
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emotional suffering often caused by bereavement
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Group
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two or more people with shared purposes and goals
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Group dynamics
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forces that determine the behavior of the group and the relationships among the group members
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Harriet Tubman
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known as "The Moses of Her People" for her work with the Underground Railroad. During the Civil War she nursed the sick and suffering of her own race
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Health
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a state of being physically fit, mentally stable, and socially comfortable; it encompasses more than the state of being free of disease
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Health behaviors
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the actions a person takes to understand his or her health state, maintain an optimal state of belief, prevent illness and injury, and reach his or her maximum physical and mental potential
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Health beliefs
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concepts about health that an individual believes are true
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Health care proxy
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a legal statement that appoints a proxy to make medical decisions for the client in the event the client is unable to do so
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Health care system
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the totality of services offered by all health disciplines
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health history
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A comprehensive record of the client’s past and current health history gathered during the initial health assessment interview.
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Health maintenance organization (HMO)
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a group health care agency that provides basic and supplemental health maintenance and treatment services to voluntary enrollees
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health pattern
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A set of related traits, habits, or acts that affect a client’s health.
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Health promotion
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any activity undertaken for the purpose of achieving a higher level of health and well-being
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Health protection
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behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness
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Health risk assessment (HRA)
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an assessment and educational tool that indicates a client’s risk for disease or injury during the next 10 years by comparing the client’s risk with the mortality risk of the corresponding age, sex, and racial group
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Health status
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the health of a person at a given time
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Heart
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An intricately designed pump composed of a meticulous network of synchronized structures.
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Heart-lung death
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the traditional clinical signs of death: cessation of the apical pulse, respirations, and blood pressure
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Heimlich maneuver
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subdiaphragmatic abdominal thrusts used to clear an obstructed airway
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Helping relationships
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referred to as the nurse-client relationship
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Higher brain death
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see Cerebral death
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Homan's sign
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Diagnostic maneuver in which pain may increase with sharp dorsiflexion of the foot.
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Hospice
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the delivery of care for terminally ill clients either in health care facilities or in the client’s home
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hyperresonance
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Abnormally loud, low tone of longer duration than resonance.
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hyperthermia
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(Fever) may occur in response to viral or bacterial infections, or from tissue breakdown following myocardial infarction, malignancy, surgery, or trauma.
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hypothermia
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A response to prolonged exposure to cold.
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Illness
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a highly personal state in which the person feels unhealthy or ill, may or may not be related to disease
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Illness behavior
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the course of action a person takes to define the state of his or her health and pursue a remedy
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immunocompetence
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A biochemical assessment laboratory measurement used in nutritional assessment.
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Implementing
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the phase of the nursing process in which the nursing care plan is put into action
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Independent interventions
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activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills
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Independent practice associations (IPAs)
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provide care in offices, clients pay a fixed prospective payment and IPA pays the provider. Earnings or losses are assumed by the IPA
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Indicator
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an observable patient state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language
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Individualized care plan
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a plan tailored to meet the unique needs of a specific client--needs that are not addressed by the standardized plan
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Inductive reasoning
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making generalizations from specific data
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Infective Endocarditis
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A condition caused by bacterial infiltration of the lining of the heart’s chambers.
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Inferences
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interpretations or conclusions made based on cues or observed data
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Informal plan
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a strategy for action that exists in the nurse’s mind
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inspection
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The skill of observing the client in a deliberate, systematic manner.
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Integrated delivery system (IDS)
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a system that incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services
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interactional skills
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Actions that are used during the encoding/decoding process to obtain and disseminate information, develop relationships, and promote understanding of self and others.
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Interpersonal skills
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all the verbal and nonverbal activities people use when communicating directly with one another
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Interview
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a planned communication; a conversation with a purpose
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intractable pain
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Pain that is highly resistant to relief.
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Intuition
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the understanding or learning of things without the conscious use of reasoning
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|
Justice
|
fairness
|
|
|
Kardex
|
the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date
|
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|
kilonychia
|
A clinical finding of poor nutrition, spoon-shaped ridges in the cardia.
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|
Knights of Saint Lazarus
|
an order of knights that dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions
|
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landmarks
|
Thoracic reference points and specific anatomical structures used to help provide an exact location for the assessment findings and an accurate orientation for documentation of findings.
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|
Lavinia L. Dock
|
a nursing leader and suffragist who was active in the protest movement for women’s rights that resulted in the U.S. Constitution amendment allowing women to vote in 1920
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|
Leader
|
a person who influences others to work together to accomplish a specific goal
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Leading question
|
a question that influences the client to give a particular answer
|
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Left Atrium
|
Forms the posterior aspect of the heart.
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Left Ventricle
|
Egg shaped, most muscular chamber of the heart, located behind the right ventricle and forms the left border of the heart.
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|
Licensed vocational (practical) nurse (LVN/LPN)
|
a nurse who practices under the supervision of a registered nurse, providing basic direct technical care to clients
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|
Lifestyle
|
the values and behaviors adopted by a person in daily life
|
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|
Lillian Wald
|
founded the Henry Street Settlement and Visiting Nurse Service which provided nursing and social services and organized educational and cultural activities. She is considered the founder of public health nursing
|
|
|
listening
|
Paying undivided attention to what the client says and does.
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|
|
Living will
|
a document that states medical treatments(s) the client chooses to omit or refuse in the event that the client is unable to make these decisions
|
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|
Livor mortis
|
discoloration of the skin caused by break down of the red blood cells; occurs after blood circulation has ceased; appears in the dependent areas of the body
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|
|
Locus of control
|
(LOC) a concept about whether clients believe their health status is under their own or other’s control
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|
|
Loss
|
an actual or potential situation in which a valued ability, object, or person is inaccessible or changed so that it is perceived as no longer valuable
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|
|
lymph
|
Excess fluid from the tissue spaces.
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|
|
lymph nodes
|
Clumps of tissue located along the lymphatic vessels either deep or superficially in the body.
|
|
|
lymphatic vessels
|
Vessels that extend from the capillaries of their system to the two main lympathic trunks and form their own circulatory system in which their collected fluid flows to the heart.
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|
Maintenance stage
|
the person integrates newly adopted behavior patterns into his or her lifestyle
|
|
|
malnutrition
|
(Undernutrition) describes health effects of insufficient nutrient intake or stores.
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|
|
Managed care
|
a method of organizing care delivery that emphasizes communication and coordination of care among all health care team members
|
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|
Manager
|
one who is appointed to a position in an organization which gives the power to guide and direct the work of others
|
|
|
manual compression test
|
Test used to determine the length of varicose veins.
|
|
|
manubrium
|
The superior portion of the sternum.
|
|
|
Marfan's Syndrome
|
A degenerative disease of the connective tissue, which over time may cause the ascending aorta to either dilate or dissect, leading to abrupt death.
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|
Margaret Sanger
|
considered the founder of Planned Parenthood, was imprisoned for opening the first birth control information clinic in Baltimore in 1916
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|
Mary Breckinridge
|
a nurse who practiced midwivery in England, Australia, and New Zealand, founded the Frontier Nursing Service in Kentucky in 1925 to provide family-centered primary health care to rural populations
|
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|
Mediastinal space
|
The area where the heart sits obliquely within the thoracic cavity between the lungs and above the diaphragm.
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|
|
mediastinum
|
Part of the thorax, or thoracic cavity, that contains the heart, trachea, esophagus, and major blood vessels of the body.
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|
Medicaid
|
a United States federal public assistance program paid out of general taxes and administered through the individual states to provide health care for those who require financial assistance
|
|
|
Medical examiner
|
a physician who usually has advanced education in pathology or forensic medicine who determines causes of death
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|
Medicare
|
a national and state health insurance program for United States residents over 65 years of age
|
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|
Moral development
|
process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done
|
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|
Moral rules
|
specific prescriptions for actions
|
|
|
Morality
|
a doctrine or system denoting what is right and wrong in conduct, character, or attitude
|
|
|
Mortician
|
a person trained in the care of the dead; also called an undertaker
|
|
|
Mourning
|
the process through which grief is eventually resolved or altered
|
|
|
Multidisciplinary care plan
|
a standardized plan that outlines the care required for clients with common, predictable--usually medical--conditions
|
|
|
Mutual pretense
|
a type of awareness in which the client, family, and health personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject
|
|
|
Myocardium
|
The second, thick, muscular layer of the heart, made up of bundles of cardiac muscle fibers reinforced by a branching network of connective tissue fibers called the fibrous skeleton of the heart.
|
|
|
Narrative charting
|
a descriptive record of client data and nursing interventions, written in sentences and paragraphs
|
|
|
Neutral question
|
a question that does not direct or pressure a client to answer in a certain way
|
|
|
nociceptors
|
The receptors that transmit pain sensation.
|
|
|
Nondirective interview
|
an interview using open-ended questions and empathetic responses to build rapport and learn client concerns
|
|
|
Nonmaleficence
|
the duty to do no harm
|
|
|
Nonverbal communication
|
communication other than words, including gestures, posture and facial expressions
|
|
|
Norm
|
an ideal or fixed standard; an expected standard of behavior of group members
|
|
|
Nursing diagnosis
|
the nurse's clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
|
|
|
Nursing ethics
|
ethical issues that occur in nursing practice
|
|
|
Nursing interventions
|
any treatments, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
|
|
|
Nursing Interventions Classification (NIC)
|
see NIC
|
|
|
Nursing orders
|
instructions written on the care plan to direct the specific nursing activities that help the client achieve desired outcomes/goals
|
|
|
Nursing Outcomes Classification (NOC)see NOC
|
Policies
|
|
|
Nursing process
|
a systematic rational method of planning and providing nursing care
|
|
|
Objective data
|
information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled
|
|
|
Open awareness
|
a type of awareness in which the client and people around know about the impending death
|
|
|
Open-ended questions
|
questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic
|
|
|
Outcome evaluation
|
focuses on demonstrable changes in the client's health status as result of nursing care
|
|
|
overnutrition
|
Excesses in nutrient intake or stores.
|
|
|
Overt data
|
see Objective data
|
|
|
oxygen saturation
|
The percentage of oxygen in the blood.
|
|
|
pain
|
A highly unpleasant sensation that affects a person’s physical health, emotional health, and well-being.
|
|
|
pain
|
A highly unpleasant sensation that affects a person’s physical health, emotional health, and well-being.
|
|
|
pain rating scale
|
Assessment of the intensity of pain through the use of pain rating scales, using a numerical rating of 0 to 5 or 0 to 10, with 0 indicating the absence of pain.
|
|
|
pain threshold
|
The amount of pain stimulation the person requires to feel pain.
|
|
|
pain tolerance
|
The maximum amount and duration of pain that an individual is willing to endure.
|
|
|
Palliative care
|
symptom care of clients for whom disease no longer responds to cure-focused treatment
|
|
|
palpation
|
The skill of assessing the client through the sense of touch to determine specific characteristics of the body.
|
|
|
paraphrasing
|
Restating the client’s basic message to test whether it was understood.
|
|
|
Passive euthanasia
|
allowing a person to die by withholding or withdrawing measures to maintain life
|
|
|
Patient
|
a person who is waiting for or undergoing medical treatment and care
|
|
|
Patient Self-Determination Act (PSDA)
|
legislation requiring that every competent adult be informed in writing upon admission to a health care institution about his or her rights to accept or refuse medical care and to use advance directives
|
|
|
Patient-focused care
|
delivery model that brings all services and care providers to the client
|
|
|
Perceived loss
|
the loss experienced by a person that cannot be verified by others
|
|
|
percussion
|
"Striking through" a body part with an object, fingers, or reflex hammer, ultimately producing a measurable sound.
|
|
|
Pericardium
|
A thin sac composed of a fibroserous material that surrounds the heart.
|
|
|
peripheral vascular system
|
Blood vessels of the body that together with the heart and the lymphatic vessels make up the body’s circulatory system.
|
|
|
Personal space
|
the distance people prefer in interactions with others
|
|
|
Personal values
|
values internalized from the society or culture in which one lives
|
|
|
PES format
|
the three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms
|
|
|
Physical restraints
|
any manual method or physical or mechanical device, material, or equipment attached to the client’s body that restrict the client’s movement
|
|
|
PIE
|
an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions
|
|
|
pleximeter
|
The device that accepts the tap or blow from a hammer.
|
|
|
plexor
|
A hammer or tapping finger used to strike an object.
|
|
|
positive regard
|
The ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude.
|
|
|
Possible nursing diagnosis
|
one in which evidence about a health problem is incomplete or unclear
|
|
|
Postmortem examination
|
see Autopsy
|
|
|
Precontemplation stage
|
a person typically denies having a problem, views others as having a problem and therefore wants to change the other person’s behavior
|
|
|
Preferred provider arrangements (PPAs)
|
similar to PPOs but PPAs can contract with individual health care providers; the plan can be limited or unlimited
|
|
|
Preferred provider organization
|
(PPO) a group of physicians or a hospital that provides companies with health services at a discounted rate
|
|
|
preinteraction
|
The period before first meeting with the client in which the nurse reviews information and prepares for initial interview.
|
|
|
Preparation stage
|
occurs when the person undertakes cognitive and behavioral activities that prepare the person for change
|
|
|
Primary prevention
|
activities directed toward the protection from or avoidance of potential health risks
|
|
|
primary sources
|
The client is the best source because he can describe personal symptoms, experiences, and factors leading to the current concerns.
|
|
|
Principles-based (deontological) theories
|
emphasize individual rights, duties, and obligations
|
|
|
Priority setting
|
the process of establishing a preferential order for nursing strategies
|
|
|
Problem solving
|
obtaining information that clarifies the nature of the problem and suggests possible solutions
|
|
|
Problem-oriented medical record (POMR)
|
data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information
|
|
|
Problem-oriented record
|
(POR) see Problem-oriented medical record (POMR)
|
|
|
Procedures
|
steps used in carrying out policies or activities
|
|
|
Process evaluation
|
a component of quality assurance that focuses on how care was given
|
|
|
Process recording
|
the verbatim (word-for-word) account of a conversation
|
|
|
Profession
|
an occupation that requires extensive education or a calling that requires special knowledge, skill, and preparation
|
|
|
Professional values
|
values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers
|
|
|
Professionalism
|
a set of attributes, a way of life that implies responsibility and commitment
|
|
|
Professionalization
|
the process of becoming professional; acquiring characteristics considered to be professional
|
|
|
Progress notes
|
chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes
|
|
|
Protocols
|
a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
|
|
|
Proxemics
|
the study of distance between people in their interactions
|
|
|
pulse
|
A high-pressure wave that causes the arteries to expand and contract.
|
|
|
pulse
|
Wave of pressure felt at various points in the body due to the force of the blood against the walls of the arteries.
|
|
|
Purkinje Fibers
|
Fibers that fan out and penetrate into the myocardial tissue to spread the current into the tissues themselves.
|
|
|
Qualifiers
|
words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
|
|
|
Quality improvement
|
an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meeting and exceeding customer expectations and outcomes; also known as total quality management (TQM) and continuous quality improvement (CQI)
|
|
|
Quality-assurance program
|
an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
|
|
|
radiating pain
|
Pain perceived at the source of the pain and extends to nearby tissues.
|
|
|
rales/crackles
|
Discontinuous sounds which are intermittent, nonmusical, and brief.
|
|
|
Rapport
|
a relationship between two or more people of mutual trust and understanding
|
|
|
Rationale
|
the scientific reason for selecting a specific action
|
|
|
Raynaud's Disease
|
A condition in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis and then rubor (red color).
|
|
|
Record
|
a written communication providing formal, legal documentation of a client's progress
|
|
|
Recording
|
the process of making written entries about a client on the medical record
|
|
|
referred pain
|
Pain felt in a part of the body that is considerably removed from the tissues causing the pain.
|
|
|
reflecting
|
Letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed.
|
|
|
Relationships-based (caring) theories
|
stress courage, generosity, commitment, and the need to nurture and maintain relationships
|
|
|
Remission
|
a period during a chronic illness when there is a lessening of severity or cessation of symptoms
|
|
|
Report
|
whether oral or written, it should be concise, including pertinent information but no extraneous detail
|
|
|
resonance
|
A loud, low-pitched, hollow tone of long duration.
|
|
|
resonance
|
The usual sound in the thorax, a long, low-pitched hollow sound.
|
|
|
respiratory cycle
|
Consists of an inspiratory phase and an expiratory phase of breathing.
|
|
|
respiratory rate
|
Counting the number of exchanges of oxygen and carbon dioxide (one inspiration and one expiration) per minute.
|
|
|
Responsibility
|
the specific accountability or liability associated with the performance of duties of a particular role
|
|
|
Restraints
|
protective devices used to limit physical activity of the client or a part of the client’s body
|
|
|
Review of systems
|
see Screening examination
|
|
|
rhonchi
|
(Sonorous Wheezes) Sounds that are low-pitched with a snoring quality.
|
|
|
Right Atrium
|
A thin-walled chamber located above and slightly to the right of the right ventricle that forms the right border of the heart.
|
|
|
Right Ventricle
|
Part of heart formed triangularly and comprises much of the anterior or sternocostal surface of the heart.
|
|
|
Rigor mortis
|
the stiffening of the body that occurs after death
|
|
|
Risk factors
|
factors that cause a client to be vulnerable to developing a health problem
|
|
|
Risk factors
|
factors that cause a client to be vulnerable to developing a health problem
|
|
|
S1
|
The first heart sound (lub), is heard when the AV valves close. Closure of these valves occurs when ldrslt the ventricles have been filled.
|
|
|
S2
|
The second heart sound (dub), occurs when the aortic and pulmonic valves close, they close when the ventricles have emptied their blood into the aorta and pulmonary arteries.
|
|
|
Safety monitoring device
|
a position-sensitive switch that triggers an audio alarm when the client attempts to get out of the bed or chair
|
|
|
Sairy Gamp
|
a character in Dickens book Martin Chizzlewit, who represented the negative image of nurses in the early 1800s
|
|
|
Scald
|
a burn from a hot liquid or vapor, such as steam
|
|
|
Screening examination (review of systems)
|
a brief review of essential functioning of various body parts or systems
|
|
|
Secondary prevention
|
activities designed for early diagnosis and treatment of disease or illness
|
|
|
secondary sources
|
A person or record that provides additional information about the client.
|
|
|
Seizure
|
a sudden onset of a convulsion or other paroxysmal motor or sensory activity
|
|
|
Seizure precautions
|
safety measures taken by the nurse to protect clients from injury should they have a seizure
|
|
|
Semilunar Valves
|
Valves that separate the ventricles from the vascular system.
|
|
|
Shroud
|
a large piece of plastic or cotton material used to enclose a body after death
|
|
|
Signs
|
see Overt data
|
|
|
Sinoatrial Node
|
The node located at the junction of the superior vena cava and right attrium that initiates the electrical impulse.
|
|
|
SOAP
|
an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning
|
|
|
Socialization
|
a process by which a person learns the ways of a group or society in order to become a functioning participant
|
|
|
Socratic questioning
|
a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes
|
|
|
Sojourner Truth
|
an abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, she was a nurse for over 4 years during the Civil War and worked as a nurse and counselor for the Freedman’s Relief Association after the war
|
|
|
Source-oriented record
|
a record in which each person or department makes notations in a separate section or sections of the client’s chart
|
|
|
sphygmomanometer
|
A blood pressure cuff.
|
|
|
Standard
|
a generally accepted rule, model, pattern, or measure
|
|
|
Standardized care plan
|
preprinted guides for giving nursing care of clients with common needs (eg, a nursing diagnosis)
|
|
|
Standards of care
|
detailed guidelines describing the minimal nursing care that can reasonably be expected to ensure high quality care in a defined situation (eg, a medical diagnosis or a diagnostic test)
|
|
|
Standards of clinical nursing practice
|
descriptions of the responsibilities for which nurses are accountable
|
|
|
Standing order
|
a written document about policies, rules, regulations, or orders regarding client care; give nurses the authority to carry out specific actions under certain circumstances
|
|
|
Status epilepticus
|
continuous seizures
|
|
|
Sternum
|
The flat, narrow center bone of the upper anterior chest.
|
|
|
Stroke Volume
|
The amount of blood that is ejected with every heartbeat.
|
|
|
Structure evaluation
|
focuses on the setting in which care is given
|
|
|
Subjective data
|
data that are apparent only to the person affected; can be described or verified only by that person
|
|
|
summarizing
|
Tying together the various messages that the client has communicated throughout the interview.
|
|
|
Supplemental Security Income (SSI)
|
special payments for people with disabilities, those who are blind, people who are not eligible for Social Security; these payments are not restricted to health care costs
|
|
|
Symptoms
|
see Covert data
|
|
|
Syndrome diagnosis
|
a diagnosis that is associated with a cluster of other diagnoses
|
|
|
Systole
|
The phase of ventricular contraction in which the ventricles have been filled, then contract to expel blood into the aorta and pulmonary arteries.
|
|
|
Taxonomy
|
a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles
|
|
|
Teacher
|
a nurse who helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health
|
|
|
Team nursing
|
the delivery of individualized nursing care to clients by a team led by a professional nurse
|
|
|
Technical skills
|
"hands-on" skills such as those required to manipulate equipment, administer injections, and move or reposition patients
|
|
|
Telecommunications
|
The transmission of information from one site to another, using equipment to transmit information in the forms of signs, signals, words, or pictures by cable, radio, or other systems
|
|
|
temperature
|
Core temperature, or the temperature of the deep tissues of the body, relatively constant at about 37ºC, or 98.6ºF.
|
|
|
Termination stage
|
the ultimate goal where the individual has complete confidence that the problem is no longer a temptation or threat
|
|
|
Territoriality
|
a concept of the space and things that individuals consider their own
|
|
|
Tertiary prevention
|
activities designed to restore disabled individuals to their optimal level of functioning
|
|
|
Therapeutic communication
|
an interactive process between nurse and client that helps the client overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks which stand in the way of self-realization
|
|
|
tracheal sounds
|
Harsh, high-pitched sounds heard over the trachea when the client inhales and exhales.
|
|
|
tympany
|
A loud, high-pitched, drumlike tone of medium duration characteristic of an organ that is filled with air.
|
|
|
Undertaker
|
see Mortician
|
|
|
Utilitarianism
|
a specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of persons; often used in making decisions about the funding and delivery of health care
|
|
|
Utility
|
the principle of utilitarianism
|
|
|
Validation
|
the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data
|
|
|
Value set
|
all the values (eg, personal, professional, religous) that a person holds
|
|
|
Value system
|
the organization of a person's values along a continuum of relative importance
|
|
|
Values
|
something of worth; a belief held dearly by a person
|
|
|
Values clarification
|
a process by which individuals define their own value
|
|
|
Variance
|
a variation or deviation from a critical pathway; goals not met or interventions not performed according to the time frame
|
|
|
varicosities
|
Distended veins that are dilated but have a diminished blood flow and an increased intravenous pressure.
|
|
|
veins
|
Parts of systemic circulation that deliver deoxygenated blood from the body periphery back to the heart.
|
|
|
venous insufficiency
|
Inadequate circulation in the venous system usually due to incompetent valves in deep veins or a blood clot in the veins.
|
|
|
Veracity
|
a moral principle that holds that one should tell the truth and not lie
|
|
|
Verbal communication
|
use of verbal language to send and receive messages
|
|
|
vesicular sounds
|
Sounds are soft and low-pitched and heard over the remainder of the lungs, longer on inhalation than exhalation.
|
|
|
Visceral Layer
|
The inner layer, which lines the surface of the heart.
|
|
|
visceral pain
|
Pain results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax, appears diffuse and often has feeling of pressure, burning, or aching.
|
|
|
vital signs
|
Measurement of body temperature, pulse, respiratory rate, blood pressure, and sometimes oxygen saturation to obtain baseline data, to detect or monitor a change in the client’s health status, and to monitor clients at risk for alterations in health.
|
|
|
Well-being
|
a subjective perception of balance, harmony, and vitality
|
|
|
Wellness
|
a state of well-being; engaging in attitudes and behaviors that enhance quality of life and maximize personal potential
|
|
|
Wellness diagnosis
|
(NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement
|
|
|
Wellness diagnosis
|
(NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement
|
|
|
wheezes
|
(Sibilant) Sounds that are high-pitched with a shrill quality.
|
|
|
whispered pectoriloquy
|
Auscultation of voice sounds, patient whispers "one, two, three", normal lung sounds will be faint, almost indistinquishable.
|
|
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Xanthelasma
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Yellowish cholesterol deposits seen on the eyelids and are indicative of premature atherosclerosis.
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Risk nursing diagnosis
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clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene
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