Nursing Process Key Terms

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Chapter 3

Question Answer
AuditorsPeople appointed to examine patient charts and health records to assess quality of care
Chart (health care record)legal record that is used to meet the many demands of health, accreditation, medical insurance, and legal systems
Charting By Exception (CBE)recording only new data or changes in patient status or care charting the exceptions to the previously recorded data
Computer on Wheels (COWs)point of care systems housed on wheeled carts
DatabaseLarge store or bank of information, as in forming the patient's nursing diagnosis
Diagnosis-Related Groups System that classifies patients by age, diagnoses, and surgical categories; used to predict the use hospital resources, including the length of stay
DocumentingProcess of adding information to the chart, usually at prescribed intervals
Electronic Health RecordAn electronic patient record designed for health information exchange between facilities
Electronic Medical RecordAn electronic patient record designed for health information exchange only within a facility
Informaticsstudy of information processing
Kardex (or Rand)A card system used to consolidate patient orders and care needs in a centralized, concise way.
Narrative ChartingTraditional system of charting in which the nurse documents in story form all pertinent patient observations, care, and responses in the nurse's notes section of the patient's records
Nursing Care PlanPlan of care based on a nursing assessment and a nursing diagnosis; lists nursing actions necessary to meet a patient's needs
Nursing NotesThe form on the patient's chart on which nurses record their observations, care given, and the patient's responses
Peer ReviewAn appraisal by professional co-workers (of equal status) of the way an individual nurse conducts practice, education, or research.
Personal Health RecordAn electronic record in which patients are allowed to input and update their own health information
Point-of-Care (POC)Computer electronic health record systems that are located at the patient's bedside
Problem ListPrioritized master list of the patient's active, inactive, temporary, and at-risk medical or other problems; serves as an index to the rest of the record
Problem-Oriented Medical Record (POMR)Method of recording data about the health status of a patient in a problem-solving system. Parts included are the database, problem-list, initial plan, and progress notes.
Quality assurance, Assessment, and ImprovementIn health care, any evaluation of services provided and the results achieved as compared with accepted standards.
RecordingProgress of adding written information to the chart, usually at prescribed intervals.
SBARSituation, Background, Assessment, Recommendation
SOAPESubjective, Objective, Assessment, Plan, and Evaluation
SOAPIERSubjective, Objective, Assessment, Plan, Intervention, Evaluation, and Revision
Traditional (block) chartConventional patient chart broken down into sections or blocks; included are admission data, physicians' orders, history and physical examination, using care plan, nurses' notes and graphics, progress notes, and test data.

Chapter 5

Question Answer
Actual nursing diagnosisclinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community
AssessmentEvaluation or appraisal of a condition; includes observing, gathering, verifying, and communicating pertinent data, usually information about the patient
Biographic DataThe facts and events of a person's life
Case ManagementThe assignment of a health care provider to oversee the case of a individual patient
Clinical pathwayMultidisciplinary plan that schedules clinical interventions over an anticipated time frame for a high-risk, high-volume, high-cost type of case
Collaborative problemsActual or potential health problem (complication) that focuses on the pathophysiologic response of the body for which nurses are responsible and accountable for identification and treatment in collaboration with the physician
CueWord, phrase, or symptom that indicates the nature of something perceived. Cues are grouped to assist the nurse in interpretation of data, as in formulating the patient's plan of care
DatabaseLarge store or bank of information, as in forming the patient's nursing diagnosis
Defining CharacteristicsClinical signs and symptoms that a problem exists
DiagnoseTo identify a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures
EvaluationThe determination made about the extent to which the established outcomes have been achieved in the nursing care plan
GoalThe purpose to which an effort is directed
ImplementationThe phase of the nursing process that includes ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation
Managed CareA health care system that involves administrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated, and costs are reduced. Health education and preventative medicine are emphasized.
Medical DiagnosisThe identification of a disease or condition by scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures.
NANDA-INorth American Nursing Diagnosis Association-International
Nursing DiagnosisA clinical judgment about individual, family, or community responses to actual or high-risk(potential) health problems or life processes.
Nursing InterventionsActivity performed by nurses that should promote the achievement of the desired patient outcome
Nursing ProcessSystemic method by which nurses plan and provide care for patients
Nursing-sensitive patient outcomesThe results or outcomes of nursing interventions. These outcomes or indicator are influenced by nursing and can be used to judge effectiveness of care and determine best practices.
Objective DataOf or pertaining to a clinical finding that is observed, palpated, or auscultated. Laboratory findings, as well as radiologic and other studies, are included; observable and measurable signs
OutcomeDescription of the specific measurable behavior (outcome criteria) that the patient will be able to exhibit after the nursing interventions.
PlanningIn the five-step nursing process, a category of nursing behavior in which a strategy is designed for the achievement of the goals of care for an individual patient, as established in assessing and analyzing. Planning includes developing and modifying a care plan for the patient, cooperating with other personnel, and recording relevant information.
Risk Nursing DiagnosisA clinical judgement that an individual, family or community is more vulnerable to develop the problem than others in same or similar situation
Standardized Languagesa structured vocabulary that provides nurses with a common means of communication
Subjective DataSymptoms; verbal statements provided by the patient. That which arises from within or is perceived by the individual and related to the examiner
Syndrome Nursing DiagnosisUsed when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances
VarianceThe unexpected event that occurs during the use of a clinical pathway; can be positive or negative
Wellness Nursing DiagnosisA clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level or wellness.

Chapter 11

Question Answer
Normal range BP of adultsystolic 100-120 and diastolic 70-80
Normal range of respirations12-20 per minute
Normal range for bowl sounds4-32
Constant Feverremain elevated and fluctuates a little
Intermittent Feverrise and falls and normal
remittent feverrise and falls but never normal until patient heals
above what body temperature is body at risk>105 F
Afebrileno fever
Normal range of beats per minute60-100
Normal range of body temperature97-99.6F
prehypertensive120-139 / 80-89
Cardiac outputamount of blood pumped out from ventricles per minute
Hypertension is sustainedabove 140/90
tachycardia>100 BPM
bradycardia<60 BPM
Pulse 0absent pulse
pulse 1+thready pulse which is hard to feel, hard to find if only slight pressured applied
pulse 2+weak pulse, not palpable when slight pressure
pulse 3+normal pulse, easily felt but not palpable when moderate pressure applied
pulse 4+bounding pulse, feels full and spring-like when under moderate pressure
controls the rate of respirationmedulla oblongata
Depth of Respiration determined byamount of air taken in with inhalation.. Normally 500 mL of air inspired per breath
Diaphragm during breathingDown during inspiration and Up during expiration
Sighing allows alveolito be aerated(air cell put in)
Cheyne-Stokes respirationsare abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing. Noted in the critically/terminally ill
Hyperventilationrate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases
Hypoventilationrate of ventilation entering the lungs is insufficient for metabolic needs.
Systolic pressurerepresents the ventricles contacting
Diastolic pressurerepresents the pressure within the artery between beats (between contractions of the atria and ventricles)
Pulse pressuredifference between systolic and diastolic
Orthostatic hypotensiona drop of 25 mmHg in systolic pressure and a drop of 10 mm Hg in diastolic pressure.
Korotkoff Soundspulsating sounds when taking BP and each sound represents a phase

Chapter 12

Question Answer
AcuteHaving a short and relatively severe course; a disease process characterized by a relatively short duration of signs and symptoms that are usually severe and begin abruptly
AssessmentEvaluation or appraisal of a condition; includes observing, gathering, verifying, and communicating pertinent data, usually information about the patient
AuscultationTo listen for sounds within the body to evaluate the condition of the heart, lungs, pleura, intestines, or other organs or to detect fetal heart sounds
BorborygmiLoud, gurgling sounds that accompany increased motility of the bowel
BruitsAbnormal swishing sound heard over organs, glands, and arteries
chronicDeveloping slowly and persisting or a long period, often for the remainder of an individual's life
cracklesShort, discrete, interrupted crackling or bubbling adventitious breath sounds heard on auscultation of the chest, most commonly upon inspiration. They are produced by passage of air through the bronchi that contain secretions of exudate or are constricted by spasms or thickening; usually heard during inspiration; formerly called rales.
diseaseAny disturbance of a structure or function of the body; a pathologic condition of the body
drainageFree flow or withdrawal of fluids from a wound or cavity by some sort of system such as a urinary catheter or T-tube
dullnessLow-pitched thud like sound upon percussion of the body
edemaAbnormal accumulation of fluids in interstitial spaces of tissue; a combining form meaning swelling.
erythemaRedness of inflammation of the skin or mucous membranes resulting from dilation and congestion of superficial capillaries.
etiologyThe study of all factors that may be involved in the development of a disease; the cause of disease.
exudateFluid, cells, or other substances that have been slowly exuded or discharged from body cells or blood vessels through small pores or breaks in cell membrane
flatnessSoft, high-pitched, flat sound produced by performing percussion over tissue such as muscle tissue
focused assessmentConcentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance.
functional diseaseMay be manifested as an organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities.
infectionCaused by an invasion of microorganisms such as bacteria, viruses, fungi, or parasites that produce tissue damage
inflammationProtective response of body tissues to irritation, injury, or invasion by disease-producing organisms. The cardinal signs include erythema, edema, heat, and loss of function
neoplasticAny abnormal growth of new tissue, benign or malignant
nursing health historyData collected about the patient's level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactive to illness
nursing physical assessmentIdentification by a nurse of the needs, preferences, and abilities of a patient. Assessment provides the scientific basis for a complete nursing care plan
objective dataOf or pertaining to a clinical finding that is observed, palpated, or auscultated. Laboratory findings, as well as radiologic and other studies, are included; observable and measurable signs
organic diseaseresults in a structural change in an organ that interferes with its functioning
palpationA technique used in physical examination in which the examiner feels the texture, size, consistency, and location of certain parts of the body with the hands.
percussionUsing fingertips to tap the body's surface to produce vibration and sound
pruritusThe symptoms of itching; an uncomfortable sensation leading to the urge to scratch; scratching often leads secondary infection. Some cases of pruritus are allergy, infection, elevated serum urea, jaundice, and skin irritation
purulentProducing or containing pus.
signsAn objective finding as perceived by the examiner; a sign can be seen, heard, measured, or felt by the examiner
subjective dataSymptoms; verbal statements provide by the patient. That which arises from within or is perceived by the individual and related to the examiner
symptomsSubjective indication of a disease or a change in condition as perceived by the patient
thrillFine vibration sensation along the artery, which is palpated by the examiner
turgorThe normal resiliency of the skin caused by the outward pressure of the cells and interstitial fluid; may be assessed as increased or decreased skin turgor
tympanyA high-pitched dreamlike sound produced by performing percussion over a hollow organ such as the stomach
wheezesAdventitious breath sounds that have a whistling or sighing sound resulting from narrowing of the lumen of a respiratory passageway. May be heard both on inspiration and expiration. Wheezes characteristically clear on coughing