fundamentals of nursing

Nursing

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, and advocacy in care.

Roles of a Nurse

Includes caregiver, communicator, educator, advocate, manager/leader, and researcher.

Assessment (in Nursing Process)

Gathering subjective and objective data about a patient.

Diagnosis (in Nursing Process)

Analyzing data to identify patient problems or nursing diagnoses.

Planning (in Nursing Process)

Developing a care plan, setting goals and selecting interventions.

Implementation (in Nursing Process)

Carrying out the planned interventions for patient care.

Evaluation (in Nursing Process)

Determining if patient care goals were met and revising the plan as needed.

Autonomy

The patient's right to make decisions regarding their own care.

Beneficence

The ethical principle of acting for the good of others.

Non-maleficence

The ethical principle of doing no harm.

Justice (in Ethics)

Fairness in treatment and resource distribution.

Fidelity

Loyalty and commitment to patient care.

Veracity

The ethical principle of telling the truth.

Nurse Practice Acts

State laws that regulate nursing practice.

Standards of Care

Guidelines for nursing practice that measure against a reasonable and prudent nurse.

Torts

Legal wrongs that can be intentional (assault, battery) or unintentional (negligence).

Informed Consent

Patient's agreement to a procedure after being informed of risks, benefits, and alternatives.

Health History

Subjective data related to a patient's past medical and social history.

Physical Examination

Objective data collection using techniques like inspection and palpation.

Vital Signs

Indicators of physiological status including temperature, pulse, respirations, and blood pressure.

Pain

Considered the 5th vital sign; assessed using subjective scales.

Fall Prevention

Measures to prevent falls, including proper orientation and environmental safety.

Healthcare-Associated Infections (HAIs)

Infections acquired during healthcare delivery.

Chain of Infection

The process of how infections are transmitted, including infectious agent and susceptible host.

Hand Hygiene

The first line of defense against infections; includes washing hands or using alcohol-based rubs.

Personal Protective Equipment (PPE)

Includes gloves, gowns, masks, and eye protection to prevent infection.

Rights of Medication Administration

Includes right patient, right medication, right dose, right route, right time, and right documentation.

Routes of Administration

Includes oral, parenteral, topical, and inhalation methods for medication.

Documentation

The legal record of care provided to a patient.

Therapeutic Communication

Client-centered communication that promotes trust and rapport.

SBAR

A communication tool used for hand-off reports: Situation, Background, Assessment, Recommendation.

Hygiene in Patient Care

Includes bathing, oral care, perineal care, hair care, and nail care.

Wound Healing Phases

Includes hemostasis, inflammatory, proliferative, and remodeling phases.

Wound Assessment

Evaluating the location, size, and tissue type of wounds.

Dressings

Materials used to promote healing, protect the wound, and absorb exudate.