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fundamentals vocabulary words-tammy/stacy
vocabulary words for fundamental book
1072
Medical
Professional
07/16/2011

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Term

advanced healthcare directives

 

Definition
include a variety of legal and lay documents that allow persons to specify aspects of care they wish to recieve should they become unable to make or communicate thier preferences.
Term
answer
Definition
a written response
Term
assault
Definition
attenpt or threat to touch another person unjustafiably
Term
autopsy
Definition
an examination of the body after death
Term
battery
Definition
a willful touching of a person or the persons clothes or even something the person is carrying, that may or may not cause harm
Term
breach of duty
Definition
a standard of care that is expected in a specific situation but that the nurse did not observe.
Term
burden of proof
Definition
a plaintiff must offer evidence of the defendants wrong doing.
Term
causation
Definition
it must be proved that the harm occured as a direct result of the nurses failure to follow the standard of care and the nurse could have or should have known that failure to follow the standard of care could result in such harm.
Term
civil actions
Definition
deal with relationships among individuals in society.
Term
civil law
Definition
is the body of law that deals with relationships that deal with private individuals
Term
common law
Definition
laws evolving from court decisions
Term
complaint
Definition
a document filed by a person referred to as the plaintiff who claims that his or her legal rights have been infringed on
Term
contract
Definition
agreement between two or more competent persons on sufficient considerations to do or not to do some lawful act
Term
contract law
Definition
involves the inforcement of agreements along private individuals or the payment of compensation for failure to fullfill agreements
Term
contractual obligations
Definition
nurses duty of care, duty to render care, established by the presence of an expressed or implied contract.
Term
contractual relationships
Definition
vary among practice settings maybe used as an independant or employer/employee relationship
Term
coroner
Definition
a physician who is authorized by the county or other government agency to determine causes of death under unusual circumstances
Term
credentialing
Definition
the process of determining and maintaining competence in practice includes licensure, registration, certification, and accredidation
Term
crime
Definition
an act commited in violation of public (criminal) law and punishable by a fine and/or imprisonment
Term
criminal actions
Definition
deal with disputes between an individual and the society as a whole
Term
criminal law
Definition
deals with actions against the safety and welfare of the public
Term
damages
Definition
if malpractice caused the injury the nurse is held liable for damages that may be compensated
Term
decision
Definition
legal outcome made by a judge
Term
defamation
Definition
(legal) a communication that is false, or made with a careless disregard for the truth, and results in injury to the reputation of another.
Term
defendants
Definition
(legal) person against whom a plaintiff files a complaint
Term
delegation
Definition
transfers the responsibility and authority for an activity to a competent individual
Term
discovery
Definition
(legal) pretrial activities to gain all the facts of a situation
Term
do not resuscitate (DNR)
Definition
an order generally written to indicate that when a client or proxy has expressed the wish for no resuscitation in the event of a respitory or cardiac arrest
Term
duty
Definition
the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care
Term
euthanasia
Definition
the act of painlessly putting to death persons suffering from incurable or distressing disease
Term
expert witness
Definition
one who has special training, experience, or a skill in relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise.
Term
express consent
Definition
an oral or written agreement
Term
false imprisonment
Definition
the unlawful restraint or detention of another person against his or her wishes
Term
felony
Definition
a crime of a serious nature, such as a murder, punishable a term in prison
Term
foreseeability
Definition
a link that must exist between the nurses act and injury suffered
Term
gross negligence
Definition
involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm
Term
harm
Definition
(injury) the client or plaintif must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client, the plaintiff will be asked to document physical injury, medical cost, loss of wages, "pain and suffering", and any other damages
Term
healthcare proxy
Definition
a legal statement that appoints a proxy to make medical decisions for the client in the event the client is unable to do so
Term
impaired nurse
Definition
a nurse that practice has deteriated because of chemical abuse
Term
implied consent
Definition
consent that is assumed in an emergency when consent can not be obtained from the client or relative
Term
implied contract
Definition
a contract that has not been explicitly agreed to by the parties but the law neverless considers to exist
Term
imformed consent
Definition
a clients agreement to accept a course of treatment or a procedure after recieving complete information, including the risk of treatment and facts relating to it, from the healthcare provider
Term
injury
Definition
see harm
Term
inquest
Definition
a legal iquiry into the cause or manner of a death
Term
interstate compact
Definition
an agreement between two or more states
Term
invasion of privacy
Definition
a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of revealed information of the standing of the person in the community
Term
law
Definition
a rule made by humans that regulates social conduct in a formally prescribed and binding manner
Term
liability
Definition
the quality or state of being legaly responsible for ones obligation and action and to make financial restitution for wrongful acts
Term
libel
Definition
defamation by means of print, writing, or pictures
Term
license
Definition
a legal permit granted to individuals to engage in the practice of a profession and to use a particular title
Term
litigation
Definition
the action of a lawsuit
Term
living will
Definition
a document that states medical treatments the client chooses to omit or refuse in the event that the client is unable to make these decisions
Term
malpractice
Definition
the negligent acts of persons engaged in professions or ocupations in which highly technical or professional skills are employed
Term
mandated reporters
Definition
a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities
Term
manslaughter
Definition
second degree murder
Term
medical examiner
Definition
a physician who usually has advanced education in pathology or forensic medicine who determines cause of death
Term
misdemeanor
Definition
a legal offense usually punishable by a fine or a short term jail sentence, or both
Term
mutal recognition model
Definition
a regulatory model developed by the national council of state boards of nursing (NCSBS), which allows for multistate licensure.
Term
negligence
Definition
failure to behave in a resonable and prudent manner; an unintentional tort
Term
plaintiff
Definition
a person claiming infringment of legal rights by one or more persons
Term
post mortum examination
Definition
see autopsy
Term
private law
Definition
the body of law that deals with relationships between private individuals
Term
public law
Definition
refers to the body of law that deals with relationships between individuals and the government and governmental agencies
Term
res ipsa loquiture
Definition
(the thing that speaks for itself) a legal doctrine that relates to negligence in which harm can not be traced to a specific healthcare provider or standard but does not normally occur unless their has been a negligent act
Term
respondant superior
Definition
a legal term meaning (let the master answer), the employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee
Term
responsibility
Definition
the specific accountability or liability associated with the performance of duties of a particular role
Term
right
Definition
(legal) a priviledge or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily
Term
slander
Definition
defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a reputation is damaged
Term
standards of care
Definition
the skills and learning commonly possessed by members of a profession
Term
statuatory law
Definition
a law inacted by any legislative body
Term
strike
Definition
an organized work stoppage by a group of employees to express a greivance, enforce a demand for changes in condition of employment, or solve a dispute with managment
Term
tort
Definition
a civil wrong committed against a person or persons property
Term
tort law
Definition
law that defines and enforces duties and rights among private individuals that are not based on contractual agreements or (non union)
Term
trial
Definition
the period during which all relavent facts are presented to a jury or judge
Term
unprofessional conduct
Definition
 one of the grounds for actions against the nurses license; includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using, or possessing controlled substances
Term
verdict
Definition
the outcome made by a jury
Term

chapter 26

attentive listening

Definition
listening actively, using all senses, as opposed to listening passively with just the ear
Term
boundary
Definition
the real or imaginary lines that differentiate one system from another system or a system from its environment
Term
bullying
Definition
an offense abusive, intimidating, insulting behaviour or abusive power which makes the recipient feel upset, threatened, humiliated, or vulnerable, which undetermines there self confidence and may cause them to suffer stress
Term
communication
Definition
a two way process involving the sending and receiving of messages
Term
congruent communication
Definition
the verbal and nonverbal aspects of the message match
Term
decode
Definition
to relate the message percieved to the recievers storehouse of knowledge and experience and to sort out the meaning of the message
Term
elderspeak
Definition
speach style similar to baby talk: gives the message of dependance and incompetence to older adults
Term
electronic communication
Definition
communication involving computers and technology (i.e. email)
Term
email
Definition
electronic communication
Term
emotional intelligence
Definition
the ability to form work relationships with collegues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others
Term
empathy
Definition
the ability to discriminate what the other persons world is like and to communicate to the others this understanding in a way that shows that the helper understands the clients feelings and the behaviour and experience underlying these feelings
Term
encoding
Definition
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 jestures to use.
Term
feedback
Definition
the response or message that the reciever returns to the sender during communication
Term
group
Definition
two or more people with shared purposes and goals
Term
group dynamics
Definition
forces that determine the behaviour of the group and the relationship among the group members
Term
helping relationships
Definition
the nurse client relationship
Term
incivility
Definition
rude, discourtious, or disrespectful behaviour that reflects a lack of regard for others
Term
lateral violence
Definition
also know as horizontal violence and horizontal hostility; describe physical, verbal,  or emotional abuse or aggression directed at RN coworkers at the same organization level, it usually includes verbal or nonverbal ( rather than physical) behaviours
Term
nonverbal  communication
Definition
communication other than words, including jestures, posture, and facial expressions
Term
personal space
Definition
the distance people prefer in interactions with others
Term
process recording
Definition
the verbatum (word for word) account of conversation
Term
proxemics
Definition
the study of distance between people in their interactions
Term
territoriality
Definition
a concept of the space and things that individuals consider their own
Term
therapeutic communication
Definition
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 psychologic blocks that stand in the way of self realization
Term
verbal communication
Definition
use of verbal language to send and recieve messages
Term
concept mapping
Definition
a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
Term
creativity
Definition
thinking that results in the development of new ideas and products
Term
critical analysis
Definition
a set of questions on can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas
Term
critical thinking
Definition
a cognitive process that includes creativity, problem solving, and decision making
Term
decision making
Definition
the process of establishing criteria by which alternative courses of action are developed and selected
Term
deductive reasoning
Definition
making specific observations from a generalization
Term
inductive reasoning
Definition
making generalizations from specific data
Term
intuition
Definition
the understanding or learning of things without the conscious use of reasoning
Term
nursing process
Definition
a systematic rational method of planning and providing nursing care
Term
problem solving
Definition
obtaining information that clarifies the nature of the problem and suggests possible solutions
Term
socratic questioning
Definition
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.
Term
trial and error
Definition
a number of approaches are tried until a solution is found.
Term
acquired immunity
Definition
a resistance of the body to infection in which the host receives natural or artificial antibodies pro due by another source
Term
active immunity
Definition
a resistance of the body to infection in which the host produces its own antibodies in response to natural or artificial antigens
Term
acute infection
Definition
those that generally appear suddenly or last a short time
Term
airborne precautions
Definition
used for clients known to have or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns
Term
antibodies
Definition
immunoglobins, part of the bodys plasma proteins, defend primarily against the extracellular phases of bacterial and viral infections
Term
antigen
Definition
a substance capable of inducing the formation of antibodies
Term
antiseptics
Definition
an agent that inhibits the growth of some microorganisms
Term
asepsis
Definition
freedom from infction or infectious material
Term
autoantigen
Definition
an antigen that originates in a persons own body
Term
bacteremia
Definition
bacteria in the blood
Term
bacteria
Definition
the most common infection causing microorganism
Term
bloodborne pathogens
Definition
potentially infectious organisms that are carried in and transmitted through blood or materials containing blood
Term
carrier
Definition
a person or animal that harbors a specific infectious agent and serves as a potential source of infection, yet does not manifest any clinical signs of disease
Term
cell mediated defenses
Definition
occurs through the t-cell system
Term
cellular immunity
Definition
also known as cell mediated defensed, occur through the t-cell system
Term
chronic infection
Definition
infection that occurs slowly, over a very long period, and may last months or years
Term
circulating immunity
Definition
antibody mediated defense; resides ultimately in the b lymphocytes and is mediated by the antibodies produced by b cells
Term
clean
Definition
free of potentially infectious agents
Term
colonization
Definition
the presence of organisms in body secretions or excretions in which strains of bacteria become resident flora but do not cause illness
Term
communicable disease
Definition
a disease that can spread from one person to another
Term
compromised host
Definition
any person at increased risk for an infection
Term
contact precautions
Definition
used for clients known or suspected to have serious illnesses easily transmitted by direct client contact or by contact with items in the clients invironment (GI, respiratory, skin or wound infections, etc)
Term
cultures
Definition
laboratory cultivations of microorganisms in a special growth medium
Term
dirty
Definition
denotes the likely resence of microorganisms, some of which may be capable of causing infection
Term
disease
Definition
an alteration in body function resulting in a reduction of capacities or shortening of the normal life span
Term
disinfectants
Definition
agent that destroys microorganisms other than spores
Term
droplet nuclei
Definition
residue of evaporated droplets emitted by an infected host, such as someone with tuberculosis, that can remain in the air for long periods of time
Term
droplet precautions
Definition
used for clients known or suspected to have serous illnesses transmitted by particle droplets larger than 5 microns (diphtheria, micro plasma, pneumonia)
Term
endogenous
Definition
developing from within
Term
exogenous
Definition
developing from outside sources
Term
exudate
Definition
purulent drainage
Term
fungi
Definition
infection causing microorganism that include yeasts and molds
Term
granulation tissue
Definition
young connective tissue with new capillaries formed in the wound healing process
Term
Healthcare associated infection (HAI)
Definition
infections that originate in any health care setting
Term
humoral immunity
Definition
antibody-mediated defense; resides ultimately in the B lymphocytes and is mediated by the antibodies produced by B cells
Term
iatrogenic infections
Definition
infections that are the direct result of diagnostic or therapeutic procedures
Term
immune defenses
Definition
are directed against identifiable bacteria, viruses, fungi, or other infectious agents
Term
immunity
Definition
a specific resistance of the body to infection; it may be natural, or resistance may develop after exposure to a disease agent
Term
immunoglobins
Definition
part of the bodys plasma proteins, defend primarily against the extracelluylar phases of bacterial and viral infections.
Term
infection
Definition
the disease process produced by microorganisms
Term
inflammation
Definition
local and nonspecific defensive tissue response to injury or destruction of cells
Term
isolation
Definition
practices that prevent the spread of infection and communicable disease
Term
leukocytes
Definition
white blood cells
Term
leukocytosis
Definition
an increase in the number of white blood cells
Term
local infection
Definition
an infection that is limited to the specific part of the body where the microorganisms remain
Term
medical asespis
Definition
all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and spread of microorganisms
Term
nonspecific defenses
Definition
bodily defenses that protect a person against all microorganisms, regardless of prior exposure
Term
nosocomial infections
Definition
infections that originate in a hospital
Term
occupational exposure
Definition
skin, ye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duties
Term
opportunistic pathogen
Definition
a microorganism causing disease only in a susceptible individual
Term
parasites
Definition
microorganisms that live in or on another fro which it obtains nourishment
Term
passive immunity
Definition
a resistance of the body to infection in which the host receives natural or artificial antibodies prodded by another source
Term
pathogenicity
Definition
the ability to produce disease; a pthaoge is a microorganism that causes disease
Term
regeneration
Definition
renewal, regrowth, the replacement of destroyed tissue cells by cells that are identical or similar in structure and function
Term
reservoirs
Definition
a source of microorganisms
Term
resident flora
Definition
microorganisms that normally reside on the skin and mucous membranes, and inside the respiratory and gastrointestinal tracts
Term
respiratory hygiene/ cough etiquette
Definition
covering the mouth and nose when sneezing or coughing, proper disposal of tissues, and separating potentially infected persons from others by at least 1 m or 3 ft or having them wear a surgical mask.
Term
sepsis
Definition
the presence of pathogenic organisms or their toxins in the blood or body tissues
Term
septicemia
Definition
occurs when bacteria resuts in systemic infection
Term
specific defenses
Definition
immune functions directed against identifiable bacteria, viruses, fungi, or other infectious agents
Term
standard precautions
Definition
the risk of caregiver exposure to client body tissues and fluids rather than the suspected presence or absence of infectious organisms determines the use of clean gloves, gowns, masks, and eye protection
Term
sterile field
Definition
a microorganism free area
Term
sterile technique
Definition
practices that keep an area or object free of all microorganisms
Term
sterilization
Definition
a process that destroys all microorganisms, including spores and viruses
Term
surgical asepsis
Definition
practices that keep an area or object free of all microorganisms; also call sterile technique
Term
systemic infection
Definition
occurs when pathogens spread and damage different parts of the body
Term
universal precautions
Definition
techniques to be used with all clients ot decrase the risk of transmitting unidentified pathogens; currently, stardar precautions incorporate universal precautions and BSI
Term
vector borne transmission
Definition
transport of an infectious agent from an animal or flying or crawling insect that serves as an intermediate means via biting or depositing feces or other materials on the skin
Term
vehicle borne transmission
Definition
transport of an infectious agent into a susceptible host via any intermediate substance (e.g. for mites or food)
Term
virulence
Definition
ability to produce disease
Term
viruses
Definition
nucleic acid-based infectious agents
Term
asphyxiation
Definition
lack of oxygen due to interrupted breathing
Term
bioterrorism
Definition
intentional attack using biological weapons such as viruses, bacteria, or other germs
Term
burn
Definition
results from excessive exposure to thermal, chemical, electric, or radioactive agents
Term
carbon monoxide
Definition
an odorless, odorless, tasteless gas that is very toxic
Term
chemical restraints
Definition
medications used to control socially disruptive behavior
Term
electric shock
Definition
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
Term
heimlich maneuver
Definition
abdominal thrusts used to clear an obstructed airway
Term
physical restraints
Definition
any manual method or physical or mechanical device, material, or equipment attached to the client's body that cannot be removed easily and that restricts the clients movement
Term
restraints
Definition
protective devices used to limit physical activity of the client or a part of the body
Term
safety monitor devices
Definition
an electronic sensor or monitor that detects when clients are attempting to get out of a bed or chair and triggers an alarm
Term
scald
Definition
a burn from a hot liquid or vapor, such as steam
Term
seizure
Definition
a single tempoary event that consists of an uncontrolled electrical neuronal discharge of the brain resulting in an interruption of normal brain function.
Term
seizure precautions
Definition
safety measure taken to protect clients from injury should they have a seizure
Term
alopecia
Definition
the loss of scalp hair (baldness) or body hair
Term
apocrine glands
Definition
sweat glands located largely in the axillae and anogenital areas; they begin to function at puberty under the influence of androgens
Term
bactericidal
Definition
bacteria-killing action
Term
callus
Definition
a thickened portion of th skin
Term
cerumen
Definition
earwax
Term
cleansing baths
Definition
a bath given for hygienic purposes
Term
corn
Definition
a conical, circular, painful, raised area on the toe or foot
Term
cross contamination
Definition
the movement of microorganisms from one client to another via soiled linen
Term
dandruff
Definition
a diffuse scaling of the scalp, often accompanied by itching
Term
dental caries
Definition
tooth decay
Term
eccrine glands
Definition
glands that produce sweat; found over most of the body
Term
fissures
Definition
deep grooves that occur as a result of dryness and cracking of the skin
Term
gingiva
Definition
the gums of the mouth
Term
gingivitis
Definition
red, swollen gingiva or gums
Term
hirsutism
Definition
the growth of excessive body hair
Term
hygiene
Definition
the science of health and its maintenance
Term
ingrown toenail
Definition
the growing inward of the nail into the soft tissues around it, most often results from improper nail trimming
Term
lanugo
Definition
the fine, woolly hair or down on the shudders, back, sacrum, and earlobes of the unborn child that may remain for a few weeks after birth
Term
pediculosis
Definition
infestation with head lice, pedicures capitis; body lice, pedicures corporis; or crab lice, pedicures pubus
Term
periodontal disease
Definition
disorder of the supporting structures of the teeth
Term
plantar warts
Definition
a wart on the sole of the foot
Term
plaque
Definition
an invisible soft film consisting of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes that adheres to the enamel suface of teeth.
Term
pyorrhea
Definition
advanced periodontal disease in which teeth are loose and pus is evident when the gums are pressed
Term
sebum
Definition
the oily, lubricating secretion of sebaceous glands in the skin
Term
scabies
Definition
a contagious skin infestation by the itch mite that produces intense itching, especially at night
Term
sudoriferous glands
Definition
glands of the dermis that secrete sweat
Term
sweat glands
Definition
glands that secrete sweat
Term
tartar
Definition
a visible, hard deposit of plaque and dead bacteria that forms at the gum lines.
Term
therapeutic baths
Definition
a bath given for physical effects, such as to soothe irritated skin or to promote healing of an area (e.g the perineum); two common types are the sitz bath and the medicated bath
Term
ticks
Definition
small gray-brown parasites that bite into tissue and suck blood and transmit several diseases to people in particular Rocky Mountain spotted fever, Lyme disease, and tularemia
Term
tine pedis
Definition
athlete's foot (ringworm of the foot), which is caused by a fungus
Term
xerostomia
Definition
dry mouth as a result of a reduced supply of saliva
Term
cephalocaudel
Definition
proceeding in the direction from head to toe
Term
closed questions
Definition
restrictive question requiring only a short answer
Term
cues
Definition
any piece of information or data that influences decisions
Term
data
Definition
information
Term
database
Definition
all information about a client, includes nursing health history and physical assessment, physicians history, physical examination, and laboratory and diagnostic test results
Term
directive interview
Definition
a highly structured iterview that uses closed questions to elicit specific information
Term
inferences
Definition
interpretations or conclusions made based on cues or observed data
Term
interview
Definition
a planed communication; a conversation with a purpose
Term
leading question
Definition
A QUESTION THAT INFLUENCES THAT CLIENT TO GIVE A PARTICULAR ANSWER
Term
neutral question
Definition
a question that does not direct or pressure a client to answer in a certain way
Term
non directive interview
Definition
an interview using open-ended questions and empathetic responses to build rapport and learn client concerns
Term
nursing process
Definition
a systematic rational method of planning and providing nursing care
Term
objective data
Definition
information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled
Term
open-ended questions
Definition
questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic.
Term
rapport
Definition
a relationship between two or more people of mutual trust and understanding
Term
review of systems
Definition
a brief review of essential functioning of various body parts or systems
Term
screening examination
Definition
(review of systems) a brief review of essential functioning of various body parts or systems
Term
signs
Definition
detectable by an observer or can be measured or tested against an accepted standard.
Term
subjective data
Definition
dates that are apparent only to the person affected; can be desribed or verified only bu that person
Term
symptoms
Definition
information (data) apparent only to the person affected that can be described or verified only by that person.
Term
validation
Definition
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 diagnoses is justified by the data
Term
defining characteristics
Definition
client signs and symptoms that must be present to validate a nursing diagnosis
Term
dependent functions
Definition
with regard to medical diagnoses, physician prescribed therapies and treatments nurses are obligated to carry out
Term
diagnoses
Definition
a statement or conclusion concerning the nature of some phenomenon
Term
diagnostic labels
Definition
title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association NANDA standardized taxonomy of terms
Term
etiology
Definition
the causual relationship between a problem and its related or risk factors
Term
health promotion diagnoses
Definition
relates to clients preparedness to implement behaviors to improve their health condition.
Term
independent functions
Definition
the area of health care that are unique to nursing and separate and distinct from medical management.
Term
norm
Definition
generally excepted measure, rule, model, or pattern.
Term
nursing diagnoses
Definition
causual relationship between a problem and its related or risk factors
Term
PES format
Definition
the three essential components of nursing diagnostic statements including the terms describing the proble, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms
Term
qualifiers
Definition
words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
Term
risk factors
Definition
factors that cause a client to be vulnerable to developing a health problem
Term
risk nursing diagnoses
Definition
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
Term
standard
Definition
a generally accepted rule, model, pattern, or measure
Term
syndrome diagnoses
Definition
a diagnoses that is associated with a cluster of other diagnoses
Term
taxonomy
Definition
a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles
Term
wellness diagnosis
Definition
NANDA describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement
Term
collaborative care plans
Definition
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
Term
collaborative interventions
Definition
actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians
Term
concept map
Definition
a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
Term
critical pathways
Definition
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
Term
dependent interventions
Definition
activities carried out on the orders of supervision of a licensed physician or other health care provider authorized to write orders for nurses
Term
discharge planning
Definition
the process of anticipating and planning for client needs after discharge
Term
formal nursing care plan
Definition
a written or computerized guide that organizes information about the clients care
Term
goals/ desired outcome
Definition
a part of a care plan that desribes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
Term
independent interventions
Definition
activities that the nurse is licensed to initiate as a result of the nurses own knowledge and skills
Term
indicator
Definition
an observable client state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language
Term
individualized care plan
Definition
a plan tailored to meet the unique needs of a specific client- needs are not addressed by the standardized plan
Term
informal nursing care plan
Definition
a strategy for action that exists in the nurses mind
Term
multidisciplinary care plan
Definition
a standardized plan that outlines the care required for clients with common, predictable -- usually medial-- conditions
Term
nursing intervention
Definition
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
Term
nursing interventions classification
Definition
a taxonomy of nursing actions each of which includes a label, a definition, and a list of activities
Term
nursing outcome classification
Definition
a taxonomy for describing client outcomes that respond to nursing interventions
Term
policies
Definition
rules developed to govern the handling of frequently occurring situations
Term
priority setting
Definition
the process of establishing a preferential order for nursing strategies
Term
procedures
Definition
steps used in carrying out policies or activities
Term
protocols
Definition
a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
Term
rationale
Definition
the scientific reason for selecting a specific action
Term
standardized care plan
Definition
formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction)
Term
standing order
Definition
an order that may be carried out indefinitely until another order is written to cancel it, or that may be carried out for a specified number of days
Term
audit
Definition
examination or review of records
Term
cognitive skills
Definition
intellectual skills that include problem solving, decision making, critical thinking and creativity
Term
concurrent audit
Definition
evaluation of a clients health care while the client is still receiving care from the agency
Term
evaluating
Definition
a planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes
Term
evaluation statement
Definition
a statement that consists of two part: a conclusion and supporting data
Term
implementing
Definition
the phase of the nursing process in which the nursing care plan is put into action
Term
interpersonal skills
Definition
all verbal and nonverbal activities people use when communicating directly with one another
Term
outcome evaluation
Definition
focuses on demonstrable changes in the clients health status as result of nursing care
Term
process evaluation
Definition
a component of quality assurance that focuses on how care was given
Term
quality assurance program
Definition
an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
Term
quality improvement
Definition
an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meting and exceeding customer expectations and outcomes
Term
retrospective audit
Definition
evaluation of a clients record after dishrag from an agency
Term
root cause analysis
Definition
process for identifying factors that bring about deviations in practices that lead to an event
Term
sentinel event
Definition
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
Term
structure evaluation
Definition
focuses on the setting which care is given
Term
technical skills
Definition
hands on skills such as those required to manipulate equipment, administer injections, and move or reposition clients
Term
adventitious breath sounds
Definition
abnormal breath sounds that occur when air pases through narrowed airways or airways filled with fluid or muss, or when pleural linings are inflamed
Term
apnea
Definition
a complete absence of respirations
Term
atelectisis
Definition
collapse of the air sacs
Term
biots reparations
Definition
shallow breaths interrupted by apnea
Term
bradypnea
Definition
abnormally slow pulse rate, less than 60 beats per minute
Term
cheyne-stokes respirations
Definition
rhythmic wxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage
Term
cyanosis
Definition
a bluish tinge of skin color
Term
diffusion
Definition
the mixing of molecules of ions of two or more substances asa result of random motion
Term
dyspnea
Definition
difficult or labored breathing
Term
emphysema
Definition
a chronic pulmonary condition in which the alveoli are dilated and distended
Term
erthyrocytes
Definition
red blood cells, or RBC's
Term
eupnea
Definition
normal, quiet breathing
Term
expectorate
Definition
spit out
Term
hematocrit
Definition
the proportion of red blood cells erythrocytes to the total blood volume
Term
hemoglobin
Definition
the red pigment in red blood cells that carries oxygen
Term
hemothorax
Definition
the accumulation of blood in the pleural cavity
Term
humidifiers
Definition
a device that adds water vapor to inspired air
Term
hypercapnia
Definition
a condition in which carbon dioxide accumulates in the blood
Term
hypercarbia
Definition
acumilation of carbon dioxide in the blood
Term
hyperinflation
Definition
giving the client breaths that are greater than the clients normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag
Term
hyper oxygenation
Definition
increasing the oxygen flow before suctioning and between suction attempts to avoid suction related hypoxemia
Term
hyperventilation
Definition
very deep, rapid respirations
Term
hypoxemia
Definition
low partial pressure of oxygen or low saturation of oxhemoglovin in the arterial blood
Term
hypoxia
Definition
insufficient oxygen anywhere in the body
Term
incentive spirometers
Definition
a device that measures the flow of air inhaled through a mouthpiece
Term
intrapleural pressure
Definition
pressure in the pleural cavity surrounding the lungs
Term
intrapulmonary pressure
Definition
pressure in the pleural cavity surrounding the lungs
Term
kussmauls breathing
Definition
hyperventilation that accompanies metabolic acidosis in whih the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing
Term
lung compliance
Definition
expansibility of the lung
Term
lung recoil
Definition
the tendency of lungs to collapse away from the chest wall
Term
mucus clearance device
Definition
used with clients with excessive secretions such as cystic fibrosis, copd, and bronchiectasis.
Term
noninvasive ventilation
Definition
delivery of air or oxygen under pressure without the need for an invasive tube such as an endotracheal tube or tracheostomy tube.
Term
orthopnea
Definition
ability to breathe only when in an upright position (sitting or standing)
Term
oxyhemoglobin
Definition
the compound of oxygen and hemoglobin
Term
partial pressure
Definition
the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture
Term
pleural effusion
Definition
is when there is excessive fluid in the pleural space. The air, blood, or fluid in the pleural space places pressure on lung tissue and interferes with lung expansion.
Term
pneumothorax
Definition
accumulation of air in the pleural space
Term
postural drainage
Definition
positioning of a client to allow the drainage, by gravity, of secretions from the lungs
Term
respiratory membrane
Definition
where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane
Term
sputum
Definition
the mucous secretion from the lungs, bronchi, and trachea
Term
stridor
Definition
a harsh, crowing sound made on inhalation caused by constrition of the upper airway
Term
suctioning
Definition
the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet
Term
surfactant
Definition
a surface active agent (e.g., soap or a synthetic detergent), in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properties of pulmonary tissue
Term
tachynpea
Definition
abnormally fast respirations; usually more than 24 respirations per minute
Term
tidal volume
Definition
the volume of air that is normally inhaled and exhaled
Term
torr
Definition
millimeters of mercury
Term
vibration
Definition
a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions
Term
afterload
Definition
the resistance that the ventricle must overcome during systole to eject blood into the circulation
Term
atherosclerosis
Definition
the buildup of fatty plaques within the arteries
Term
atria
Definition
two upper chambers of the heart
Term
atrioventricular  (AV) node
Definition
area of the heart where electrical impulsesfrom SA node converge prior to initiating ventricular contraction
Term
atrioventricular(AV) valve
Definition
valves between the atria and the ventricles
Term
automaticity
Definition
ability of cardiac muscle to generate electrical impulses and contractions indepentently of the nervous system
Term
blood pressure(BP)
Definition
force exertedon arterial walls by the blood within the vessel
Term
Bundle of His
Definition
one of three ventericular conduction pathways
Term
Cardiac output(CO)
Definition
amount of blood pumped by the ventricles in 1 minute
Term
contractility
Definition
inherent ability of cardiac muscle fibers to shorten and contract
Term
Coronary arties
Definition
net work of vessels that supply heart muscle with oxygen and nourishment
Term
creatine kinase (CK)
Definition
enzyme that is released into the blood as a result of cell membrane damage to cardiac muscle
Term
C-reactive protien(CRP)
Definition
screening test for inflammatory process in cardiovascular disease
Term
diastole
Definition
characterized by ventricular filling
Term
endocardium
Definition
lines inside of the heart's chambers
Term
epicardium
Definition
hearts outermost layer
Term
heart failure
Definition
inability of the heart to keep up with the body's need for oxygen and nutrents to the tissues
Term
hemoglobin
Definition
components of RBC's that binds easily with oxygen
Term
homocysteine
Definition
amino acid that may indicate an increased risk for circulatory events when elevated
Term
ischemia
Definition
lack of blood supply due to obstucted circulation
Term
Metabolic syndrome(Met-S)
Definition
Cluster of cardiovascular risk factors
Term
myocardial infarction(MI)
Definition
condition in which cardiac tissue becomes necrotic and dies
Term
myocardium
Definition
cardiac muscle cells that form the bulk of the heart
Term
pericrdium
Definition
a double layer membrane that surrounds the heart
Term
peripheral vascular resistance(PVR)
Definition
impedes blood flow to the tissues
Term
preload
Definition
degree to which muscle fibers in the ventrical are streched at the end of diastole
Term
purkinje fibers
Definition
terminate in ventricular muscle, stimulating contraction
Term
semilunar valves
Definition
valves between the ventricles and the great vessels
Term
septum
Definition
characterized by ventricular filing
Term
sinoatrial(SA or sinus) node
Definition
primary pacemaker of the heart
Term
systole
Definition
contraction of heart muscle and ejection of blood
Term
stroke volume(SV)
Definition
amount of blood ejected with each contraction
Term
troponin
Definition
enzyme released as a result of cell membrane damage during an MI; measured with CK
Term
ventricles
Definition
two lower chambers in the heart
Term
Afebrile
Definition
a client who does not have a fever
Term
apical pulse
Definition
a central pulse
Term
apical-radial
Definition
normally identical
Term
apenea
Definition
absence of breathing
Term
arrhythmia
Definition
pulse with an irregular rythm
Term
arterial blood pressure
Definition
the measure of the pressure exerted by the blood as it flows through the arteries
Term
arteriosclerosis
Definition
the loss of elastic and muscular tissue in the arteries
Term
auscultatory gap
Definition
a tempory disappearance of sound normally heard over the brachial artery when the cuff pressure is high followed by the reapperance of sound at a lower level
Term
basal metabolic rate(BMR)
Definition
rate of energy utilization in the body required to maintain essential activities such as breathing
Term
body temperture
Definition
reflects the balance between heat prouced and heat lost from the body
Term
bradycardia
Definition
heart rate in adult less than 60 bpm
Term
cardiac output
Definition
volume of blood pumped into the arties by the heart
Term
compliance
Definition
the ability of arteries to contract and expand
Term
conduction
Definition
the transfer of heat from one molecule to a molecule of lower temperature
Term
constant fever
Definition
body temperature fluctuates minimually but always remains above normal
Term
convection
Definition
despersion of heat by air currents
Term
core temperature
Definition
temperature of the deep tissues of the body
Term
costal(thoracic)breathing
Definition
involves the external intercostal muscles
Term
diaphragmatic(abdominal) breathing
Definition
observered by the movement of the abdomen with contraction and downward movement with breathing
Term
diastolic pressure
Definition
prussure when the ventricles are at rest
Term
dysrhythmia
Definition
arrhythmia
Term
exhalation
Definition
breathing out
Term
expiration
Definition
exhalation
Term
febrile
Definition
client who has fever
Term
fever
Definition
body temperture above the usual range
Term
fever spike
Definition
temperture that rises to fever level rapidly following a normal temperture, then returns to normal within a few hours
Term
heat balance
Definition
when the amount of heat produce by the body equals the amount of heat lost
Term
heat exhaustion
Definition
the result of excessive heat and dehydration and includes a moderately increased temperature
Term
heat stroke
Definition
signs may include high temperture, warm, dry flushed skin, and delirium
Term
hematocrit
Definition
proportion of red blood cells to blood plasma
Term
hyperpyreia
Definition
a very high fever
Term
hypertension
Definition
blood pressure persistently above normal
Term
hyperthermia
Definition
fever
Term
hyperventilation
Definition
very deep rapid respirations
Term
hypotension
Definition
blood pressure that is below normal
Term
hypothermia
Definition
core body temperture below the lower limit of normal
Term
hypoventilation
Definition
very shallow respirations
Term
inhalation
Definition
inspiration
Term
insensible heat loss
Definition
continuous heat loss through the respiratory tract and skin
Term
insensible water loss
Definition
continuous and unnoticed water loss through the respiratory tract and skin
Term
inspiration
Definition
intake of air into lungs
Term
intermittent fever
Definition
body temperature alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures
Term
Korotkoff's sounds
Definition
sounds heard when taking a blood pressure using a stethoscope
Term
orthostatic hypotension
Definition
a blood pressure that falls when a patient sits or stands
Term
oxygen saturation(SaO2)
Definition
the percent of all hemoglobin binding sites that are occupied by oxygen
Term
peripheral pulse
Definition
a pulse located away from the heart
Term
point of maximal impulse(PMI)
Definition
apical pulse
Term
pulse
Definition
a wave of blood created by contraction of the left ventrical of the heart
Term
pulse deficit
Definition
any descrepancy between the apical and radial pulses
Term
pulse oximeter
Definition
a non invasive device that estimates a clients arterial blood oxygen saturation
Term
pulse pressure
Definition
the difference between the diastolic and systolic pressures
Term
pulse rhythm
Definition
pattern of the beats and intervals between the beats
Term
pulse volume
Definition
force of blood with each beat
Term
pyrexia
Definition
hyperthermia or fever
Term
radiation
Definition
transfer of heat from the surface of one object to the surface of another without contact between the two objects
Term
relapsing fever
Definition
short febrile periods of a few days that are interspersed with periods of 1-2 days of normal temperature
Term
remittent fever
Definition
a wide range of temperature fluctuations occur over the 24 hour period, all of which are above normal
Term
respiration
Definition
the act of breathing
Term
respiratory character
Definition
those aspects to those aspects of breathing that are different from effortless, normal breathing
Term
respiratory quality
Definition
respiratory charactor
Term
respiratory rhythm
Definition
regularity of the expirations and inspirations
Term
sphygmomanometer
Definition
indicates the pressure within the bladder
Term
surface temperature
Definition
tempurature of the skin, subcutaneous tissue, and fat
Term
systolic pressure
Definition
the pressure of the blood as a result of the contraction of the ventricles
Term
tachycardia
Definition
excessively fast heart rate
Term
tachypnea
Definition
abnormally fast respirations
Term
assimilation
Definition
the process by which an individual develops a new cultural idenity
Term
tidal volume
Definition
the normal volume of air taken in with respiration
Term
vaporization
Definition
continuous vaporization of moisture from the respirtory tract and from mucosa of mouth and skin
Term
ventilation
Definition
the movement of air in and out the lungs
Term
vital signs
Definition

body temp, BP, respirations, pain, and pulse

(TPRBPpain)

Term
acute pain
Definition
pain that last only through the expected recovery period
Term
allodynia
Definition
nonpainful stimuli that produces pain
Term
agonist analgesic
Definition
pure opioid drugs that provide maximum pain inhibition
Term
agonist-antagonist analesic
Definition
can act like opioids and relieve pain when given to a client who has not taken any pure opioids
Term
cancer pain
Definition
pain associated with the disease, treatment, or other factors associated with cancer
Term
central neuropathic pain
Definition
results from malfunctioning nerves in the central nervous system (spinal cord injury pain)
Term
chronic pain
Definition
prolonged, usually recurring or lasting more than 3 months, interfers with functioning
Term
coanalgesic
Definition
not classified as a pain medication but may reduce pain alone or in combination with other analgesics; may potentiate the effects of pain medications
Term
dysesthesia
Definition
unpleasent, abnormal sensation that can be either spontaneous or evoked
Term
effleurage
Definition
type of massage consisting of long, slow, gilding strokes
Term
biomedical health belief
Definition
based on the belief that life is controlled by physical and biochemical processes that can be manipulated by humans
Term
culture
Definition
learned and shared patterns of information that a group uses to generate meanings among the members
Term
equianalgesia
Definition
refers to relative potency of various opioid analgesics compared to a standard dose of parental morphine
Term
fifth vital sign
Definition
pain assessment
Term
cultural broker
Definition
one who engages both parties effectively in accessing the nuances and hidden sociocultural assumptions embedded in each other's language
Term
hyperalgesia
Definition
increased sensation of pain in response to a normally painful stimulus
Term
hyperpathia
Definition
hyperalgesia
Term
mild pain
Definition
1-3 on a 0-10 pain scale
Term
moserate pain
Definition
rated 4-5 on a 0-10 pain scale
Term
nerve block
Definition
chemical interruption of a nerve pathway, effected by injecting a local anesthetic into the nerves
Term
neuropathic pain
Definition
pain that is related to damaged or malfunctioning nervous tissue
Term
nociception
Definition
pyhsiological processes related to pain perception
Term
nociceptive pain
Definition
experienced when an intact properly functioning nervous system sends signals that tissues are damaged
Term
nociceptors
Definition
specialized pain receptors
Term
(nsaids)  nonsteroidal anti-inflammatory drugs
Definition
a nonopioid pain medicaiton that has anti-inflammatory, analgesic, and antipyretic effects
Term
pain
Definition
an unplesant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
Term
pain management
Definition
alleviation of pain or reduction in pain to a level of comfort that is acceptable to the client
Term
pain threshold
Definition
least amount of stimuli necessary for a person to label a sensation as pain
Term
pain tolerance
Definition
the most pain an individual is willing or able to bear before taking evasive actions
Term
patient-controlled analgesia(PCA)
Definition
interactive method of pain management that permits clients to treat their pain by self administering doses of analgesics
Term
peripheral neuropathic pain
Definition
phantom limb pain
Term
placebo
Definition
any medication that produces effect in a client resulting in implicit or explicit intent, not from its physical or chemical properties
Term
preemptive analgesia
Definition
administration of analgesia before surgery to decrease or relieve pain after surgery
Term
pseudoaddiction
Definition
contion that results from the undertreatment of pain where the client may become hyper-focused on obtaining medication
Term
referred pain
Definition
pain that is felt in a site other than the location of its origin
Term
severe pain
Definition
described as a 7-10 on a pain scale of 0-10
Term
somatic pain
Definition
originates in skin, muscles, bone, or connective tissue
Term
sympathetically maintained pain
Definition
may occur with abnormal connections between pain fibers and the sympathetic nervous system perpetuate problems with pain and SNS functions
Term
(TENS) transcutaneous electrical nerve stemulation
Definition
method of applying electrical stimulation directly over identified pain areas; stimulation through to block transmission of nociceptive impulse
Term
visceral pain
Definition
pain arising from organs
Term
culturally responsive care
Definition
centered on client's cultural perspectives, integrating client's values and beliefs into the plan of care
Term
acculturation
Definition
involuntary process occurs when people incorporate traits from another culture
Term
bicultural
Definition
a person who has dual patterns of identification and crosses two cultures, lifestyles and sets of values
Term
discrimination
Definition
differntial and negative treatment of individuals on the basis of their race, ethnicity, gender or other group membership
Term
diversity
Definition
refers to the fact or state of being different
Term
ethnicity
Definition
relationship between individuals who believe that they have distinctive characteristics that make them a group
Term
ethnocentrism
Definition
belief in the superiority of one's own culture and lifestyle
Term
folk medicine
Definition
beliefs and practices relating to illness and healing that derive from cultural traditions rather than modern medicine's scientific base
Term
generalizations
Definition
statements about common cultural patterns
Term
health disparities
Definition
differences in care experienced by one population compared with another papulation
Term
heritage
Definition
things passed down from previous generations
Term
heritage consistent
Definition
client who identifies with traditional cultural heritage
Term
heritage inconsistent
Definition
client who had acculturated into dominant culture of modern society in which they reside
Term
holistic health belief
Definition
holds that forces of nature must be maintained in balance of illness results
Term
interpreter
Definition
able to transform message expressed in source language into its equivalent in the target language so that interpreted message has potential of eliciting the same response in the listener as the original heritage
Term
magico-religious health belief
Definition
view in which health and illness are
Term
nationality
Definition
refers to country where one has membership
Term
predjudice
Definition
preconceived notion or judgment that is not based on sufficient knowledge
Term
race
Definition
social and cultural characteristics as well as ancestry
Term
racism
Definition
assumption held about racial groups that include belief that races are inherently unequal
Term
religion
Definition
a system of beliefs, practices and ethical values about divine or superhuman power worshipped as the creator and ruler of the universe.
Term
scientific health belief
Definition
biomedical health beliefs
Term
stereotyping
Definition
assumption that an individual reflects all characteristics associated with being a member of the group
Term
subculture
Definition
composed of people who have a distinct identity and yet are related to a large cultural group
Term
traditional
Definition
things passed down from previous generations
Term
transcultural nursing
Definition
centered on the client's cultured perspectives, integrating the client's values, and beliefs into the plan of care
Term
translator
Definition
converts written material from one language to another
Term
change-of-shift report
Definition
purpose is to provide continuity of care for clients by providing critical information to oncoming nurses
Term
chart
Definition
client record
Term
charting
Definition
process of making an entry on a client record
Term
charting by exception(CBE)
Definition
documentation system in which only abnormal or significant findings are recorded
Term
client record
Definition
chart or record that can be written or computer based
Term
discussion
Definition
informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem
Term
documentation
Definition
process of charting or recording
Term
flow sheet
Definition
uses specific assessment criteria in a particular format
Term
focus charting
Definition
makes client concerns and strengths the focus of care, usually using three columns
Term
handoff communication
Definition
process in which information about patient care is communicated in a consistent manner including an opportunity to ask and respond to questions
Term
kardex
Definition
concise method of organizing and recording data about a client making information quickly accessible to all health professionals
Term
narrative charting
Definition
consists of notes that include routine care, normal findings, and client problems
Term
PIE
Definition
acronym for problems, interventions, and evaluations of nursing care
Term
POMR
Definition
data are arranged according to the problems a patient has rather than the source of the information
Term
POR
Definition
problem-oriented record
Term
progress note
Definition
chart entry made by all health professionals involved in a client's care
Term
record
Definition
formal legal document that provides evidence of a client's care
Term
recording
Definition
process of charting or documenting
Term
report
Definition
oral,written, or computer-based communication intended to convey information to others
Term
SOAP
Definition
acronym for subject, objective, assessment, and plan
Term
source-oriented record
Definition
each person or department makes notations ina separate section of the client's chart
Term
variance
Definition
a goal not met in a critical pathway
Term
adventitious
Definition
abnormal breath sounds
Term
alopecia
Definition
hair loss
Term
Angle of Louis
Definition
the junction between the body of the sternum and the manubrium
Term
antihelix
Definition
the anterior curve of the auricle's upper aspect
Term
aphasia
Definition
any defect or loss of the power to express oneself by speech, writing or signs, or to comprehend spoken or written language
Term
astigmatism
Definition
an uneven curvature of the cornea
Term
auricle
Definition
the part of the ear that includes the lobule, helix, antihelix, tragus, triangular fossa and external auditory meatus
Term
auscultation
Definition
the process of listening to sounds produced within the body
Term
blanch test
Definition
carried out to test peripheral circulation
Term
bruit
Definition
a blowing or swishing sound
Term
caries
Definition
cavities(tooth decay)
Term
cataracts
Definition
opacity of the lens or its capsule
Term
cerumen
Definition
earwax
Term
clubbing
Definition
condition in which the angle between the nail and the nail bed is 190 degrees or greater
Term
cochlea
Definition
a seashell-shaped structure found in the inner ear
Term
conductive hearing loss
Definition
result of interrupted transmission of sound waves through the outer and middle ear structure.
Term
conjunctivitis
Definition
inflammation of the bulbar and palpebral conjunctiva
Term
cyanosis
Definition
a bluish tinge
Term
dacryocystitis
Definition
inflammation of the lacrimal sac
Term
diastole
Definition
period in which the ventricle relaxes
Term
dullness
Definition
thud-like sound produced by dense tissue such as the liver, spleen, or heart
Term
duration
Definition
length
Term
edema
Definition
the presence of excess interstitial fluid
Term
erythema
Definition
skin rendess
Term
eustachian tube
Definition
connects the middle ear to the nasopharynx
Term
exophthalmos
Definition
protrusion of the eyeballs with elevation of the upper eyelids
Term
external auditory meatus
Definition
entrance to the ear canal
Term
extinction
Definition
failure to perceive touch on one side of the body when two symmetric areas of the body are touched simultaneously
Term
fasciculation
Definition
an abnormal contraction of a bundle of muscle fibers that appear as a twitch
Term
flatness
Definition
extremely dull sound produced by very dense tissue such as muscle or bone
Term
fremitus
Definition
faintly perceptible vibration
Term
gingivitis
Definition
red swollen gums
Term
glaucoma
Definition
a disturbance in the circulation of aqueous fluid which increases intraocular pressure
Term
glossitis
Definition
inflammation of the tongue
Term
goniometer
Definition
a device that measures the angle of the joint in degrees
Term
helix
Definition
the posterior curve of the auricle's upper aspects
Term
hernia
Definition
a protrusion of the intestine through the inguinal wall or canal
Term
horodeolum (sty)
Definition
a redness, swelling and tenderness of the hair follicle and glands that empty at the edge of the eyelids
Term
hyperopia
Definition
farsightedness
Term
hyperresonance
Definition
an abnormal booming count on percussion, often over an emphysematous lung
Term
incus
Definition
one of three bones in the middle ear, also known as anvil
Term
inspection
Definition
the visual examination
Term
intensity
Definition
refers to the loudness or softness of a sound
Term
intention tremor
Definition
becomes more apparent when an individual attempts a voluntary movement
Term
jaundice
Definition
a yellowish tinge
Term
lift
Definition
refer to a rising along the sternal border with each heartbest
Term
lobule
Definition
earlobe
Term
malleus
Definition
the hammer
Term
manubrium
Definition
the handlike superior part of the sternum that joins with the clavicles
Term
mastiod
Definition
a bony prominence behind the ear
Term
miosis
Definition
constricted pupils
Term
miosis
Definition
constricted pupils
Term
mixed hearing loss
Definition
combination of conduction and sensorineural loss
Term
mydriasis
Definition
enlarged pupils
Term
myopia
Definition
nearsightedness
Term
normocephalic
Definition
normal head size
Term
nystagmus
Definition
rapid involuntary rhythmic eye movement
Term
one-point discrimination
Definition
the ability to sense if one point on the skin is being stimulated by pressure
Term
ossicles
Definition
the bones of sound transmission
Term
otoscope
Definition
instrument for examining the ear
Term
pallor
Definition
paleness
Term
palpation
Definition
examination of the body using the sense of touch
Term
parotitis
Definition
inflammation of the parotid salivary gland
Term
periodontal disease
Definition
pyorrhea
Term
percussion
Definition
the act of striking the body surface to elicit sounds or vibrations
Term
perfusion
Definition
blood supply to an area
Term
PERRLA
Definition
pupils equally round and react to light and accommodation
Term
pinna
Definition
auricle
Term
pitch
Definition
the frequency of vibrations
Term
plaque
Definition
invisible soft film that adheres to the enamel surface of teeth
Term
pleximeter
Definition
the object placed against a body area and struck to elicit sound during percussion
Term
plexor
Definition
the finger used to strike the pleximeter
Term
precordium
Definition
area of the chest overlaying the heart
Term
presbyopia
Definition
loss of elasticity of the lens, and thus loss of the ability to see close objects
Term
proprioceptors
Definition
sensory nerve terminals that give information about movements and position of the body
Term
pyorrhea
Definition
characterized by gingivitis, bleeding, receding gum lines, formation of pockets between teeth and gums
Term
quality
Definition
description
Term
reflex
Definition
automatic response of the body to a stimuli
Term
resonance
Definition
hollow sound elicited by percussion
Term
resting tremor
Definition
diminishes with activity, more apparent when client is at rest
Term
S1
Definition
the first heart sound, occurs when the AV valves close
Term
S2
Definition
Made when the semilunar valves cllose
Term
semicircular canals
Definition
organ within the inner ear that contains organs of equilibrium
Term
sensorineural hearing loss
Definition
results from damage in the inner ear,auditory nerve or the hearing center of the brain
Term
sordes
Definition
accumulation of foul matter on the teeth and gums
Term
stapes
Definition
the stirrup-shaped bone of the middle ear
Term
stereognosis
Definition
the act of recognizing objects by touching and manipulating them
Term
sternum
Definition
breastbone
Term
strabismus
Definition
cross-eye
Term
systole
Definition
period in which the ventricles contract
Term
tartar
Definition
visible, hard deposit of plaque and dead bacteria that form at gun lines
Term
thrill
Definition
a vibrating sensation like the purring of a cat or warm water running through a hose
Term
tragus
Definition
the cartilaginous protrusion at the entrance to the ear canal
Term
tremor
Definition
an involuntary trembling of a limb or body part
Term
triangular fossa
Definition
a depression in the antihelix
Term
two-point discrimination
Definition
the ability to sense whether one or two areas of the skin are being stimulated by pressure
Term
tympanic membrane
Definition
eardrum
Term
tympany
Definition
presence of gas
Term
vestibule
Definition
an organ in the inner ear that works with the semicircular canals to maintain equilibrium
Term
visual acuity
Definition
the degree of detail the eye can discern in an image
Term
visual fields
Definition
the area an individual can see when looking straight ahead
Term
vitiligo
Definition
patches of hypopigmented skin caused by destruction of melanocytes
Term
abdominal paracentesis
Definition
procedure during which ascites is removed from the abdominal cavity to relieve pressure or obtain a specimen
Term
angiography
Definition
a radiopaque is injected into the vessel to be examined, and flow through the vesssel's is assessed
Term
anoscopy
Definition
viewing of the anal canal
Term
aterial blood gases
Definition
taking of arterial blood specimen from the radial, brachial, or femoral artery for assessment
Term
ascites
Definition
abnormal amount of peritoneal fluid accumulated in the abdominal cavities
Term
aspiration
Definition
withdrawal of fluid that has abnormally collected
Term
biopsy
Definition
removal and examination of tissue
Term
blood chemistry
Definition
tests performed on blood serum that provide valuable diagnostic cues
Term
blood urea nitrogen (BUN)
Definition
measurement of the end product of protein metabolism
Term
cannula
Definition
tube
Term
clean-catch urine specimen
Definition
midstream voided specimen
Term
clean voided urine specimen
Definition
specimen that is used for routine examinations
Term
colonoscopy
Definition
direct viewing of the large intestine
Term
complete blood count (CBC)
Definition
includes hemoglobin, hematocrit, erthrocyte count, leucocyte count,red blood cell indices, differential white cell count
Term
computed tomography (CT scan)
Definition
a painless, noninvasive x-ray procedure that produces a three-dimensional image of the organ or structures
Term
creatinine
Definition
produced by the muscles,
and relates to renal excretory function
Term
cystoscope
Definition
a lighted instrument inserted through the urethra
Term
cystoscopy
Definition
procedure during which the bladder, ureteral orifices and urethra can be directly visualized
Term
echocardiogram
Definition
a noninvasive test that uses ultrasound to visualize structure of the heart and evaluate left ventricle function
Term
electrocardiogram (EEG)
Definition
the recorded wave forms of the electrical impulses of the heart
Term
electrocardiography
Definition
provides a graphic recording of the heart's electrical activity
Term
expectorate
Definition
spit out
Term
guaiac test
Definition
a test for occult
Term
hematocrit
Definition
the percentage of RBC's in the plasma
Term
hemoglobin
Definition
the iron containing protein in the RBC's that transports oxygen through the body
Term
Hemoglobin A1C (HbA1C)
Definition
measurement of blood glucose that is bound to hemoglobin,and is a reflection of how well blood glucose levels have been controlled in the prior 3-4 months
Term
hemoptysis
Definition
blood in the sputum
Term
intravenous pyelography (IVP)
Definition
a test that evaluates the urinary tract during which contrast medium is injected intraveniouly
Term
Kidneys/ureter/bladder(KUB)
Definition
An x-ray of the kidneys, ureters, and bladder
Term
leukocytes
Definition
white blood cells
Term
lumbar puncture
Definition
a procedure performed to obtain a specimen of cerebrospinal fluid
Term
lung scan
Definition
a scan that indicates how well gas and blood are traveling through the lungs
Term
magnetic resonance imaging (MRI)
Definition
noninvasive diagnostic scanning technique in which the client is placed in a magnetic field
Term
manometer
Definition
a glass or plastic tube calibrated in millimeters that is used to measure a pressure reading
Term
midstream urine specimen
Definition
a urine specimen obtained when a urine culture is ordered
Term
occult blood
Definition
hidden blood; often a test performed on the stool
Term
peak level
Definition
indicates the highest concentration of the drug in the blood serum
Term
phlebotomist
Definition
a person from the laboratory who performs venipuncture
Term
polycythemia
Definition
higher than normal RBC count
Term
positive emission tomography(PET)
Definition
a noninvasive radiologic study that involves injection or inhalation of a radioisotope
Term
proctoscopy
Definition
direct viewing of the rectum
Term
proctosigmoidoscopy
Definition
direct viewing of the rectum and the colon
Term
radiopharmaceutical
Definition
a pharmaceutical labeled with a radioisotope
Term
reagent
Definition
substance used in a chemical reaction to detect a specific substance
Term
red blood cell count(RBC)
Definition
the number of RBC's per cubic millmeter of whole blood
Term
red blood cell(RBC) indices
Definition
evaluate the size, weight, and hemoglobin concentration of RBC's
Term
retrograde pyeloghraphy
Definition
a test to evaluate the urinary tract during which contrast medium is instilled directly into the kidney pelvis via the uretha, bladder, and ureters
Term
salivia
Definition
clear liquid secreted by the salivary glands
Term
serum osmolality
Definition
a measure of the solute concentration of the blood used to evaluate fluid balance
Term
specific gravity
Definition
indicator of urine concentration
Term
sputum
Definition
mucous secretion from the lungs, bronchi, and trachea
Term
steatorrhea
Definition
fat in the stool
Term
stress electrocardiography
Definition
uses ECGs to assess the client's response to an increased cardiac workload during exercise
Term
thoracentesis
Definition
procedure used to remove excess fluid or air from the pleural cavity
Term
trocar
Definition
a sharp-pointed instrument used in the performance of para-or thoracentesis
Term
trough level
Definition
represents the lowest cencentration of a drug in the blood serum
Term
ultrasonography
Definition
a noninvasive test that uses reflected sound waves to visualize internal organs or structures
Term
urine osmolatity
Definition
measure of the solute concentration of the urine, used to monitor fluid balance
Term
venipuncture
Definition
the drawing of blood for testing
Term
White blood cell count(WBC)
Definition
determines the number of circulating leukocytes per cubic millimeter of whole blood
Term
assault
Definition
attenpt or threat to touch another person unjustafiably
Term
autopsy
Definition
an examination of the body after death
Term
battery
Definition
a willful touching of a person or the persons clothes or even something the person is carrying, that may or may not cause harm
Term
breach of duty
Definition
a standard of care that is expected in a specific situation but that the nurse did not observe.
Term
burden of proof
Definition
a plaintiff must offer evidence of the defendants wrong doing.
Term
causation
Definition
it must be proved that the harm occured as a direct result of the nurses failure to follow the standard of care and the nurse could have or should have known that failure to follow the standard of care could result in such harm.
Term
civil actions
Definition
deal with relationships among individuals in society.
Term
civil law
Definition
is the body of law that deals with relationships that deal with private individuals
Term
common law
Definition
laws evolving from court decisions
Term
complaint
Definition
a document filed by a person referred to as the plaintiff who claims that his or her legal rights have been infringed on
Term
contract
Definition
agreement between two or more competent persons on sufficient considerations to do or not to do some lawful act
Term
contract law
Definition
involves the inforcement of agreements along private individuals or the payment of compensation for failure to fullfill agreements
Term
contractual obligations
Definition
nurses duty of care, duty to render care, established by the presence of an expressed or implied contract.
Term
contractual relationships
Definition
vary among practice settings maybe used as an independant or employer/employee relationship
Term
coroner
Definition
a physician who is authorized by the county or other government agency to determine causes of death under unusual circumstances
Term
credentialing
Definition
the process of determining and maintaining competence in practice includes licensure, registration, certification, and accredidation
Term
crime
Definition
an act commited in violation of public (criminal) law and punishable by a fine and/or imprisonment
Term
criminal actions
Definition
deal with disputes between an individual and the society as a whole
Term
criminal law
Definition
deals with actions against the safety and welfare of the public
Term
damages
Definition
if malpractice caused the injury the nurse is held liable for damages that may be compensated
Term
decision
Definition
legal outcome made by a judge
Term
defamation
Definition
(legal) a communication that is false, or made with a careless disregard for the truth, and results in injury to the reputation of another.
Term
defendants
Definition
(legal) person against whom a plaintiff files a complaint
Term
delegation
Definition
transfers the responsibility and authority for an activity to a competent individual
Term
discovery
Definition
(legal) pretrial activities to gain all the facts of a situation
Term
do not resuscitate (DNR)
Definition
an order generally written to indicate that when a client or proxy has expressed the wish for no resuscitation in the event of a respitory or cardiac arrest
Term
duty
Definition
the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care
Term
euthanasia
Definition
the act of painlessly putting to death persons suffering from incurable or distressing disease
Term
expert witness
Definition
one who has special training, experience, or a skill in relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise.
Term
express consent
Definition
an oral or written agreement
Term
false imprisonment
Definition
the unlawful restraint or detention of another person against his or her wishes
Term
felony
Definition
a crime of a serious nature, such as a murder, punishable a term in prison
Term
foreseeability
Definition
a link that must exist between the nurses act and injury suffered
Term
gross negligence
Definition
involves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm
Term
harm
Definition
(injury) the client or plaintif must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client, the plaintiff will be asked to document physical injury, medical cost, loss of wages, "pain and suffering", and any other damages
Term
healthcare proxy
Definition
a legal statement that appoints a proxy to make medical decisions for the client in the event the client is unable to do so
Term
impaired nurse
Definition
a nurse that practice has deteriated because of chemical abuse
Term
implied consent
Definition
consent that is assumed in an emergency when consent can not be obtained from the client or relative
Term
implied contract
Definition
a contract that has not been explicitly agreed to by the parties but the law neverless considers to exist
Term
imformed consent
Definition
a clients agreement to accept a course of treatment or a procedure after recieving complete information, including the risk of treatment and facts relating to it, from the healthcare provider
Term
injury
Definition
see harm
Term
inquest
Definition
a legal iquiry into the cause or manner of a death
Term
interstate compact
Definition
an agreement between two or more states
Term
invasion of privacy
Definition
a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of revealed information of the standing of the person in the community
Term
law
Definition
a rule made by humans that regulates social conduct in a formally prescribed and binding manner
Term
liability
Definition
the quality or state of being legaly responsible for ones obligation and action and to make financial restitution for wrongful acts
Term
libel
Definition
defamation by means of print, writing, or pictures
Term
license
Definition
a legal permit granted to individuals to engage in the practice of a profession and to use a particular title
Term
litigation
Definition
the action of a lawsuit
Term
living will
Definition
a document that states medical treatments the client chooses to omit or refuse in the event that the client is unable to make these decisions
Term
malpractice
Definition
the negligent acts of persons engaged in professions or ocupations in which highly technical or professional skills are employed
Term
mandated reporters
Definition
a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities
Term
manslaughter
Definition
second degree murder
Term
medical examiner
Definition
a physician who usually has advanced education in pathology or forensic medicine who determines cause of death
Term
misdemeanor
Definition
a legal offense usually punishable by a fine or a short term jail sentence, or both
Term
mutal recognition model
Definition
a regulatory model developed by the national council of state boards of nursing (NCSBS), which allows for multistate licensure.
Term
negligence
Definition
failure to behave in a resonable and prudent manner; an unintentional tort
Term
plaintiff
Definition
a person claiming infringment of legal rights by one or more persons
Term
post mortum examination
Definition
see autopsy
Term
private law
Definition
the body of law that deals with relationships between private individuals
Term
public law
Definition
refers to the body of law that deals with relationships between individuals and the government and governmental agencies
Term
res ipsa loquiture
Definition
(the thing that speaks for itself) a legal doctrine that relates to negligence in which harm can not be traced to a specific healthcare provider or standard but does not normally occur unless their has been a negligent act
Term
respondant superior
Definition
a legal term meaning (let the master answer), the employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee
Term
responsibility
Definition
the specific accountability or liability associated with the performance of duties of a particular role
Term
right
Definition
(legal) a priviledge or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily
Term
slander
Definition
defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a reputation is damaged
Term
standards of care
Definition
the skills and learning commonly possessed by members of a profession
Term
statuatory law
Definition
a law inacted by any legislative body
Term
strike
Definition
an organized work stoppage by a group of employees to express a greivance, enforce a demand for changes in condition of employment, or solve a dispute with managment
Term
tort
Definition
a civil wrong committed against a person or persons property
Term
tort law
Definition
law that defines and enforces duties and rights among private individuals that are not based on contractual agreements or (non union)
Term
trial
Definition
the period during which all relavent facts are presented to a jury or judge
Term
unprofessional conduct
Definition
 one of the grounds for actions against the nurses license; includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using, or possessing controlled substances
Term
verdict
Definition
the outcome made by a jury
Term

chapter 26

attentive listening

Definition
listening actively, using all senses, as opposed to listening passively with just the ear
Term
boundary
Definition
the real or imaginary lines that differentiate one system from another system or a system from its environment
Term
bullying
Definition
an offense abusive, intimidating, insulting behaviour or abusive power which makes the recipient feel upset, threatened, humiliated, or vulnerable, which undetermines there self confidence and may cause them to suffer stress
Term
communication
Definition
a two way process involving the sending and receiving of messages
Term
congruent communication
Definition
the verbal and nonverbal aspects of the message match
Term
decode
Definition
to relate the message percieved to the recievers storehouse of knowledge and experience and to sort out the meaning of the message
Term
elderspeak
Definition
speach style similar to baby talk: gives the message of dependance and incompetence to older adults
Term
electronic communication
Definition
communication involving computers and technology (i.e. email)
Term
email
Definition
electronic communication
Term
emotional intelligence
Definition
the ability to form work relationships with collegues, display maturity in a variety of situations, and resolve conflicts while taking into consideration the emotions of others
Term
empathy
Definition
the ability to discriminate what the other persons world is like and to communicate to the others this understanding in a way that shows that the helper understands the clients feelings and the behaviour and experience underlying these feelings
Term
encoding
Definition
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 jestures to use.
Term
feedback
Definition
the response or message that the reciever returns to the sender during communication
Term
group
Definition
two or more people with shared purposes and goals
Term
group dynamics
Definition
forces that determine the behaviour of the group and the relationship among the group members
Term
helping relationships
Definition
the nurse client relationship
Term
incivility
Definition
rude, discourtious, or disrespectful behaviour that reflects a lack of regard for others
Term
lateral violence
Definition
also know as horizontal violence and horizontal hostility; describe physical, verbal,  or emotional abuse or aggression directed at RN coworkers at the same organization level, it usually includes verbal or nonverbal ( rather than physical) behaviours
Term
nonverbal  communication
Definition
communication other than words, including jestures, posture, and facial expressions
Term
personal space
Definition
the distance people prefer in interactions with others
Term
process recording
Definition
the verbatum (word for word) account of conversation
Term
proxemics
Definition
the study of distance between people in their interactions
Term
territoriality
Definition
a concept of the space and things that individuals consider their own
Term
therapeutic communication
Definition
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 psychologic blocks that stand in the way of self realization
Term
verbal communication
Definition
use of verbal language to send and recieve messages
Term
concept mapping
Definition
a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
Term
creativity
Definition
thinking that results in the development of new ideas and products
Term
critical analysis
Definition
a set of questions on can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas
Term
critical thinking
Definition
a cognitive process that includes creativity, problem solving, and decision making
Term
decision making
Definition
the process of establishing criteria by which alternative courses of action are developed and selected
Term
deductive reasoning
Definition
making specific observations from a generalization
Term
inductive reasoning
Definition
making generalizations from specific data
Term
intuition
Definition
the understanding or learning of things without the conscious use of reasoning
Term
nursing process
Definition
a systematic rational method of planning and providing nursing care
Term
problem solving
Definition
obtaining information that clarifies the nature of the problem and suggests possible solutions
Term
socratic questioning
Definition
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.
Term
trial and error
Definition
a number of approaches are tried until a solution is found.
Term
acquired immunity
Definition
a resistance of the body to infection in which the host receives natural or artificial antibodies pro due by another source
Term
active immunity
Definition
a resistance of the body to infection in which the host produces its own antibodies in response to natural or artificial antigens
Term
acute infection
Definition
those that generally appear suddenly or last a short time
Term
airborne precautions
Definition
used for clients known to have or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns
Term
antibodies
Definition
immunoglobins, part of the bodys plasma proteins, defend primarily against the extracellular phases of bacterial and viral infections
Term
antigen
Definition
a substance capable of inducing the formation of antibodies
Term
antiseptics
Definition
an agent that inhibits the growth of some microorganisms
Term
asepsis
Definition
freedom from infction or infectious material
Term
autoantigen
Definition
an antigen that originates in a persons own body
Term
bacteremia
Definition
bacteria in the blood
Term
bacteria
Definition
the most common infection causing microorganism
Term
bloodborne pathogens
Definition
potentially infectious organisms that are carried in and transmitted through blood or materials containing blood
Term
carrier
Definition
a person or animal that harbors a specific infectious agent and serves as a potential source of infection, yet does not manifest any clinical signs of disease
Term
cell mediated defenses
Definition
occurs through the t-cell system
Term
cellular immunity
Definition
also known as cell mediated defensed, occur through the t-cell system
Term
chronic infection
Definition
infection that occurs slowly, over a very long period, and may last months or years
Term
circulating immunity
Definition
antibody mediated defense; resides ultimately in the b lymphocytes and is mediated by the antibodies produced by b cells
Term
clean
Definition
free of potentially infectious agents
Term
colonization
Definition
the presence of organisms in body secretions or excretions in which strains of bacteria become resident flora but do not cause illness
Term
communicable disease
Definition
a disease that can spread from one person to another
Term
compromised host
Definition
any person at increased risk for an infection
Term
contact precautions
Definition
used for clients known or suspected to have serious illnesses easily transmitted by direct client contact or by contact with items in the clients invironment (GI, respiratory, skin or wound infections, etc)
Term
cultures
Definition
laboratory cultivations of microorganisms in a special growth medium
Term
dirty
Definition
denotes the likely resence of microorganisms, some of which may be capable of causing infection
Term
disease
Definition
an alteration in body function resulting in a reduction of capacities or shortening of the normal life span
Term
disinfectants
Definition
agent that destroys microorganisms other than spores
Term
droplet nuclei
Definition
residue of evaporated droplets emitted by an infected host, such as someone with tuberculosis, that can remain in the air for long periods of time
Term
droplet precautions
Definition
used for clients known or suspected to have serous illnesses transmitted by particle droplets larger than 5 microns (diphtheria, micro plasma, pneumonia)
Term
endogenous
Definition
developing from within
Term
exogenous
Definition
developing from outside sources
Term
exudate
Definition
purulent drainage
Term
fungi
Definition
infection causing microorganism that include yeasts and molds
Term
granulation tissue
Definition
young connective tissue with new capillaries formed in the wound healing process
Term
Healthcare associated infection (HAI)
Definition
infections that originate in any health care setting
Term
humoral immunity
Definition
antibody-mediated defense; resides ultimately in the B lymphocytes and is mediated by the antibodies produced by B cells
Term
iatrogenic infections
Definition
infections that are the direct result of diagnostic or therapeutic procedures
Term
immune defenses
Definition
are directed against identifiable bacteria, viruses, fungi, or other infectious agents
Term
immunity
Definition
a specific resistance of the body to infection; it may be natural, or resistance may develop after exposure to a disease agent
Term
immunoglobins
Definition
part of the bodys plasma proteins, defend primarily against the extracelluylar phases of bacterial and viral infections.
Term
infection
Definition
the disease process produced by microorganisms
Term
inflammation
Definition
local and nonspecific defensive tissue response to injury or destruction of cells
Term
isolation
Definition
practices that prevent the spread of infection and communicable disease
Term
leukocytes
Definition
white blood cells
Term
leukocytosis
Definition
an increase in the number of white blood cells
Term
local infection
Definition
an infection that is limited to the specific part of the body where the microorganisms remain
Term
medical asespis
Definition
all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and spread of microorganisms
Term
nonspecific defenses
Definition
bodily defenses that protect a person against all microorganisms, regardless of prior exposure
Term
nosocomial infections
Definition
infections that originate in a hospital
Term
occupational exposure
Definition
skin, ye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duties
Term
opportunistic pathogen
Definition
a microorganism causing disease only in a susceptible individual
Term
parasites
Definition
microorganisms that live in or on another fro which it obtains nourishment
Term
passive immunity
Definition
a resistance of the body to infection in which the host receives natural or artificial antibodies prodded by another source
Term
pathogenicity
Definition
the ability to produce disease; a pthaoge is a microorganism that causes disease
Term
regeneration
Definition
renewal, regrowth, the replacement of destroyed tissue cells by cells that are identical or similar in structure and function
Term
reservoirs
Definition
a source of microorganisms
Term
resident flora
Definition
microorganisms that normally reside on the skin and mucous membranes, and inside the respiratory and gastrointestinal tracts
Term
respiratory hygiene/ cough etiquette
Definition
covering the mouth and nose when sneezing or coughing, proper disposal of tissues, and separating potentially infected persons from others by at least 1 m or 3 ft or having them wear a surgical mask.
Term
sepsis
Definition
the presence of pathogenic organisms or their toxins in the blood or body tissues
Term
septicemia
Definition
occurs when bacteria resuts in systemic infection
Term
specific defenses
Definition
immune functions directed against identifiable bacteria, viruses, fungi, or other infectious agents
Term
standard precautions
Definition
the risk of caregiver exposure to client body tissues and fluids rather than the suspected presence or absence of infectious organisms determines the use of clean gloves, gowns, masks, and eye protection
Term
sterile field
Definition
a microorganism free area
Term
sterile technique
Definition
practices that keep an area or object free of all microorganisms
Term
sterilization
Definition
a process that destroys all microorganisms, including spores and viruses
Term
surgical asepsis
Definition
practices that keep an area or object free of all microorganisms; also call sterile technique
Term
systemic infection
Definition
occurs when pathogens spread and damage different parts of the body
Term
universal precautions
Definition
techniques to be used with all clients ot decrase the risk of transmitting unidentified pathogens; currently, stardar precautions incorporate universal precautions and BSI
Term
vector borne transmission
Definition
transport of an infectious agent from an animal or flying or crawling insect that serves as an intermediate means via biting or depositing feces or other materials on the skin
Term
vehicle borne transmission
Definition
transport of an infectious agent into a susceptible host via any intermediate substance (e.g. for mites or food)
Term
virulence
Definition
ability to produce disease
Term
viruses
Definition
nucleic acid-based infectious agents
Term
asphyxiation
Definition
lack of oxygen due to interrupted breathing
Term
bioterrorism
Definition
intentional attack using biological weapons such as viruses, bacteria, or other germs
Term
burn
Definition
results from excessive exposure to thermal, chemical, electric, or radioactive agents
Term
carbon monoxide
Definition
an odorless, odorless, tasteless gas that is very toxic
Term
chemical restraints
Definition
medications used to control socially disruptive behavior
Term
electric shock
Definition
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
Term
heimlich maneuver
Definition
abdominal thrusts used to clear an obstructed airway
Term
physical restraints
Definition
any manual method or physical or mechanical device, material, or equipment attached to the client's body that cannot be removed easily and that restricts the clients movement
Term
restraints
Definition
protective devices used to limit physical activity of the client or a part of the body
Term
safety monitor devices
Definition
an electronic sensor or monitor that detects when clients are attempting to get out of a bed or chair and triggers an alarm
Term
scald
Definition
a burn from a hot liquid or vapor, such as steam
Term
seizure
Definition
a single tempoary event that consists of an uncontrolled electrical neuronal discharge of the brain resulting in an interruption of normal brain function.
Term
seizure precautions
Definition
safety measure taken to protect clients from injury should they have a seizure
Term
alopecia
Definition
the loss of scalp hair (baldness) or body hair
Term
apocrine glands
Definition
sweat glands located largely in the axillae and anogenital areas; they begin to function at puberty under the influence of androgens
Term
bactericidal
Definition
bacteria-killing action
Term
callus
Definition
a thickened portion of th skin
Term
cerumen
Definition
earwax
Term
cleansing baths
Definition
a bath given for hygienic purposes
Term
corn
Definition
a conical, circular, painful, raised area on the toe or foot
Term
cross contamination
Definition
the movement of microorganisms from one client to another via soiled linen
Term
dandruff
Definition
a diffuse scaling of the scalp, often accompanied by itching
Term
dental caries
Definition
tooth decay
Term
eccrine glands
Definition
glands that produce sweat; found over most of the body
Term
fissures
Definition
deep grooves that occur as a result of dryness and cracking of the skin
Term
gingiva
Definition
the gums of the mouth
Term
gingivitis
Definition
red, swollen gingiva or gums
Term
hirsutism
Definition
the growth of excessive body hair
Term
hygiene
Definition
the science of health and its maintenance
Term
ingrown toenail
Definition
the growing inward of the nail into the soft tissues around it, most often results from improper nail trimming
Term
lanugo
Definition
the fine, woolly hair or down on the shudders, back, sacrum, and earlobes of the unborn child that may remain for a few weeks after birth
Term
pediculosis
Definition
infestation with head lice, pedicures capitis; body lice, pedicures corporis; or crab lice, pedicures pubus
Term
periodontal disease
Definition
disorder of the supporting structures of the teeth
Term
plantar warts
Definition
a wart on the sole of the foot
Term
plaque
Definition
an invisible soft film consisting of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes that adheres to the enamel suface of teeth.
Term
pyorrhea
Definition
advanced periodontal disease in which teeth are loose and pus is evident when the gums are pressed
Term
sebum
Definition
the oily, lubricating secretion of sebaceous glands in the skin
Term
scabies
Definition
a contagious skin infestation by the itch mite that produces intense itching, especially at night
Term
sudoriferous glands
Definition
glands of the dermis that secrete sweat
Term
sweat glands
Definition
glands that secrete sweat
Term
tartar
Definition
a visible, hard deposit of plaque and dead bacteria that forms at the gum lines.
Term
therapeutic baths
Definition
a bath given for physical effects, such as to soothe irritated skin or to promote healing of an area (e.g the perineum); two common types are the sitz bath and the medicated bath
Term
ticks
Definition
small gray-brown parasites that bite into tissue and suck blood and transmit several diseases to people in particular Rocky Mountain spotted fever, Lyme disease, and tularemia
Term
tine pedis
Definition
athlete's foot (ringworm of the foot), which is caused by a fungus
Term
xerostomia
Definition
dry mouth as a result of a reduced supply of saliva
Term
cephalocaudel
Definition
proceeding in the direction from head to toe
Term
closed questions
Definition
restrictive question requiring only a short answer
Term
cues
Definition
any piece of information or data that influences decisions
Term
data
Definition
information
Term
database
Definition
all information about a client, includes nursing health history and physical assessment, physicians history, physical examination, and laboratory and diagnostic test results
Term
directive interview
Definition
a highly structured iterview that uses closed questions to elicit specific information
Term
inferences
Definition
interpretations or conclusions made based on cues or observed data
Term
interview
Definition
a planed communication; a conversation with a purpose
Term
leading question
Definition
A QUESTION THAT INFLUENCES THAT CLIENT TO GIVE A PARTICULAR ANSWER
Term
neutral question
Definition
a question that does not direct or pressure a client to answer in a certain way
Term
non directive interview
Definition
an interview using open-ended questions and empathetic responses to build rapport and learn client concerns
Term
nursing process
Definition
a systematic rational method of planning and providing nursing care
Term
objective data
Definition
information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled
Term
open-ended questions
Definition
questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic.
Term
rapport
Definition
a relationship between two or more people of mutual trust and understanding
Term
review of systems
Definition
a brief review of essential functioning of various body parts or systems
Term
screening examination
Definition
(review of systems) a brief review of essential functioning of various body parts or systems
Term
signs
Definition
detectable by an observer or can be measured or tested against an accepted standard.
Term
subjective data
Definition
dates that are apparent only to the person affected; can be desribed or verified only bu that person
Term
symptoms
Definition
information (data) apparent only to the person affected that can be described or verified only by that person.
Term
validation
Definition
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 diagnoses is justified by the data
Term
defining characteristics
Definition
client signs and symptoms that must be present to validate a nursing diagnosis
Term
dependent functions
Definition
with regard to medical diagnoses, physician prescribed therapies and treatments nurses are obligated to carry out
Term
diagnoses
Definition
a statement or conclusion concerning the nature of some phenomenon
Term
diagnostic labels
Definition
title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association NANDA standardized taxonomy of terms
Term
etiology
Definition
the causual relationship between a problem and its related or risk factors
Term
health promotion diagnoses
Definition
relates to clients preparedness to implement behaviors to improve their health condition.
Term
independent functions
Definition
the area of health care that are unique to nursing and separate and distinct from medical management.
Term
norm
Definition
generally excepted measure, rule, model, or pattern.
Term
nursing diagnoses
Definition
causual relationship between a problem and its related or risk factors
Term
PES format
Definition
the three essential components of nursing diagnostic statements including the terms describing the proble, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms
Term
qualifiers
Definition
words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
Term
risk factors
Definition
factors that cause a client to be vulnerable to developing a health problem
Term
risk nursing diagnoses
Definition
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
Term
standard
Definition
a generally accepted rule, model, pattern, or measure
Term
syndrome diagnoses
Definition
a diagnoses that is associated with a cluster of other diagnoses
Term
taxonomy
Definition
a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles
Term
wellness diagnosis
Definition
NANDA describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement
Term
collaborative care plans
Definition
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
Term
collaborative interventions
Definition
actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians
Term
concept map
Definition
a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
Term
critical pathways
Definition
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
Term
dependent interventions
Definition
activities carried out on the orders of supervision of a licensed physician or other health care provider authorized to write orders for nurses
Term
discharge planning
Definition
the process of anticipating and planning for client needs after discharge
Term
formal nursing care plan
Definition
a written or computerized guide that organizes information about the clients care
Term
goals/ desired outcome
Definition
a part of a care plan that desribes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
Term
independent interventions
Definition
activities that the nurse is licensed to initiate as a result of the nurses own knowledge and skills
Term
indicator
Definition
an observable client state, behavior, or self-reported perception or evaluation; similar to desired outcomes in traditional language
Term
individualized care plan
Definition
a plan tailored to meet the unique needs of a specific client- needs are not addressed by the standardized plan
Term
informal nursing care plan
Definition
a strategy for action that exists in the nurses mind
Term
multidisciplinary care plan
Definition
a standardized plan that outlines the care required for clients with common, predictable -- usually medial-- conditions
Term
nursing intervention
Definition
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
Term
nursing interventions classification
Definition
a taxonomy of nursing actions each of which includes a label, a definition, and a list of activities
Term
nursing outcome classification
Definition
a taxonomy for describing client outcomes that respond to nursing interventions
Term
policies
Definition
rules developed to govern the handling of frequently occurring situations
Term
priority setting
Definition
the process of establishing a preferential order for nursing strategies
Term
procedures
Definition
steps used in carrying out policies or activities
Term
protocols
Definition
a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
Term
rationale
Definition
the scientific reason for selecting a specific action
Term
standardized care plan
Definition
formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction)
Term
standing order
Definition
an order that may be carried out indefinitely until another order is written to cancel it, or that may be carried out for a specified number of days
Term
audit
Definition
examination or review of records
Term
cognitive skills
Definition
intellectual skills that include problem solving, decision making, critical thinking and creativity
Term
concurrent audit
Definition
evaluation of a clients health care while the client is still receiving care from the agency
Term
evaluating
Definition
a planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes
Term
evaluation statement
Definition
a statement that consists of two part: a conclusion and supporting data
Term
implementing
Definition
the phase of the nursing process in which the nursing care plan is put into action
Term
interpersonal skills
Definition
all verbal and nonverbal activities people use when communicating directly with one another
Term
outcome evaluation
Definition
focuses on demonstrable changes in the clients health status as result of nursing care
Term
process evaluation
Definition
a component of quality assurance that focuses on how care was given
Term
quality assurance program
Definition
an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
Term
quality improvement
Definition
an organizational commitment and approach used to continuously improve all processes in the organization with the goal of meting and exceeding customer expectations and outcomes
Term
retrospective audit
Definition
evaluation of a clients record after dishrag from an agency
Term
root cause analysis
Definition
process for identifying factors that bring about deviations in practices that lead to an event
Term
sentinel event
Definition
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
Term
structure evaluation
Definition
focuses on the setting which care is given
Term
technical skills
Definition
hands on skills such as those required to manipulate equipment, administer injections, and move or reposition clients
Term
adventitious breath sounds
Definition
abnormal breath sounds that occur when air pases through narrowed airways or airways filled with fluid or muss, or when pleural linings are inflamed
Term
apnea
Definition
a complete absence of respirations
Term
atelectisis
Definition
collapse of the air sacs
Term
biots reparations
Definition
shallow breaths interrupted by apnea
Term
bradypnea
Definition
abnormally slow pulse rate, less than 60 beats per minute
Term
cheyne-stokes respirations
Definition
rhythmic wxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage
Term
cyanosis
Definition
a bluish tinge of skin color
Term
diffusion
Definition
the mixing of molecules of ions of two or more substances asa result of random motion
Term
dyspnea
Definition
difficult or labored breathing
Term
emphysema
Definition
a chronic pulmonary condition in which the alveoli are dilated and distended
Term
erthyrocytes
Definition
red blood cells, or RBC's
Term
eupnea
Definition
normal, quiet breathing
Term
expectorate
Definition
spit out
Term
hematocrit
Definition
the proportion of red blood cells erythrocytes to the total blood volume
Term
hemoglobin
Definition
the red pigment in red blood cells that carries oxygen
Term
hemothorax
Definition
the accumulation of blood in the pleural cavity
Term
humidifiers
Definition
a device that adds water vapor to inspired air
Term
hypercapnia
Definition
a condition in which carbon dioxide accumulates in the blood
Term
hypercarbia
Definition
acumilation of carbon dioxide in the blood
Term
hyperinflation
Definition
giving the client breaths that are greater than the clients normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag
Term
hyper oxygenation
Definition
increasing the oxygen flow before suctioning and between suction attempts to avoid suction related hypoxemia
Term
hyperventilation
Definition
very deep, rapid respirations
Term
hypoxemia
Definition
low partial pressure of oxygen or low saturation of oxhemoglovin in the arterial blood
Term
hypoxia
Definition
insufficient oxygen anywhere in the body
Term
incentive spirometers
Definition
a device that measures the flow of air inhaled through a mouthpiece
Term
intrapleural pressure
Definition
pressure in the pleural cavity surrounding the lungs
Term
intrapulmonary pressure
Definition
pressure in the pleural cavity surrounding the lungs
Term
kussmauls breathing
Definition
hyperventilation that accompanies metabolic acidosis in whih the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing
Term
lung compliance
Definition
expansibility of the lung
Term
lung recoil
Definition
the tendency of lungs to collapse away from the chest wall
Term
mucus clearance device
Definition
used with clients with excessive secretions such as cystic fibrosis, copd, and bronchiectasis.
Term
noninvasive ventilation
Definition
delivery of air or oxygen under pressure without the need for an invasive tube such as an endotracheal tube or tracheostomy tube.
Term
orthopnea
Definition
ability to breathe only when in an upright position (sitting or standing)
Term
oxyhemoglobin
Definition
the compound of oxygen and hemoglobin
Term
partial pressure
Definition
the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture
Term
pleural effusion
Definition
is when there is excessive fluid in the pleural space. The air, blood, or fluid in the pleural space places pressure on lung tissue and interferes with lung expansion.
Term
pneumothorax
Definition
accumulation of air in the pleural space
Term
postural drainage
Definition
positioning of a client to allow the drainage, by gravity, of secretions from the lungs
Term
respiratory membrane
Definition
where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane
Term
sputum
Definition
the mucous secretion from the lungs, bronchi, and trachea
Term
stridor
Definition
a harsh, crowing sound made on inhalation caused by constrition of the upper airway
Term
suctioning
Definition
the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet
Term
surfactant
Definition
a surface active agent (e.g., soap or a synthetic detergent), in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properties of pulmonary tissue
Term
tachynpea
Definition
abnormally fast respirations; usually more than 24 respirations per minute
Term
tidal volume
Definition
the volume of air that is normally inhaled and exhaled
Term
torr
Definition
millimeters of mercury
Term
vibration
Definition
a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions
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