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Nurse Practice Act (NBA)

Regulations enacted by state legislature that defines the scope of practice for nurses

Board of Nursing

A licensing and regulatory body that issues nursing licenses

ANA

American Nurses Association

ANA Standards of Professional Nursing Practice

Authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform completely

ANA Standards of Professional Performance

12 additional standards that describe a nurse's professional behavior

Protocol

A detailed and documented written plan for a regimen of therapy

The joint commission

A national organization that accredits and certifies health care organizations

ADOPIE

Assessment, diagnosis, outcomes, planning, implementation, evaluation

Subjective data

Data from the subject (word of mouth)

Objective data

Reproducible date (vitals)

Primary survey

Used during every patient encounter to evaluate status of vitals

Admission assessment

A comprehensive assessment used when a patient is admitted into the facility

Ongoing assessment

A head to toe assessment completed and documented at least once a shift

Focused assessment

Used to reevaluate the status of a previously diagnosed problem

Time-lapsed reassessment

Used in long-term care facilities every few months to evaluate progress on previously identified outcomes

Primary care

Promotes wellness and prevents disease

Secondary care

Also known as acute care, occurs when someone has contracted an illness or injury that requires medical care

Tertiary care

Addresses the long-term effects from chronic illnesses or conditions with the purpose of restoring a clients maximum physical and mental function

Basic nursing care

Care that can be performed following a defined nursing procedure with minimal modification in which the responses of the client to the nursing care are predictable

ISBARR

Introduction, situation, background, assessment, request/recommendations, repeat