Nursing Process, Clinical Judgment, Delegation, Communication, and Sensory Perception - Vocabulary Flashcards

Vocabulary-style flashcards covering nursing process, clinical judgment, delegation, communication, and sensory perception concepts based on the provided lecture notes.

SMART goals

A framework for setting clear, achievable goals: Specific, Measurable, Attainable, Realistic, and Time-limited.

ABC - Airway, Breathing, Circulation

A mnemonic for the primary assessment priorities in acute care and initial management.

Subjective data

Information provided by the patient about health history, symptoms, and perceptions.

Objective data

Measurable or observable findings from exam, labs, and diagnostics.

Risk assessment (nursing)

Nursing judgment about a patient’s risk of actual or potential health problems.

Short-term goals

Goals expected to be achieved within one week.

Long-term goals

Goals that extend beyond one week.

Implementation

Nursing actions carried out to achieve goals, including teaching, independent/dependent actions, and delegation.

Independent intervention

Nursing action that can be performed without a physician’s order within the nurse’s scope.

Dependent intervention

Nursing action that requires a physician’s order (e.g., oxygen, labs, catheter).

Delegation

Transferring responsibility for a task to another healthcare worker with accountability maintained.

Right Task

The task delegated is appropriate for the delegatee’s scope and abilities.

Right Circumstance

The patient condition and setting make the task appropriate to delegate.

Right Person

The individual has the necessary knowledge/skills to perform the task.

Right Direction/Communication

Clear, concise instructions and expectations for the delegated task.

Right Supervision/Evaluation

Ongoing monitoring and evaluation of the delegated task’s outcomes.

TEAACUP

A mnemonic related to aspects of clinical judgment: Teaching, Evaluation, Assessment, Advanced interventions, Collaboration, Unstable patient, Planning.

Clinical judgment

The ability to observe, reason, prioritize, plan, act, and evaluate in patient care.

Recognize cues

Identify relevant subjective and objective data indicating patient problems.

Analyze cues

Interpret cues to determine which problems are present or likely.

Prioritize hypotheses

Rank potential patient problems to guide planning.

Generate solutions

Develop interventions to address identified problems.

Take action

Implement chosen interventions to meet goals.

Evaluate outcomes

Assess whether goals were met and modify care as needed.

Task complexity

Level of difficulty of a task that can affect accuracy and safety.

Time pressure

Urgency that can impact performance and decision-making.

Interruptions

External disruptions that can affect workflow and patient safety.

Specialty area and autonomy

Different clinical areas have varying levels of independent practice.

Nursing process

Systematic, patient-centered approach to assess, diagnose, plan, implement, and evaluate care.

Assessment (nursing process)

Data collection and analysis (cues) about patient status.

Diagnosis (nursing process)

Identification of patient problems based on collected data.

Planning (nursing process)

Setting measurable goals and selecting interventions.

Implementation (nursing process)

Carrying out the planned interventions.

Evaluation (nursing process)

Assessing effectiveness of interventions and patient outcomes.

Cues

Data from assessment used to identify patient needs and inform goals.

Care plan modification

Adjustments to the plan based on ongoing evaluation to improve quality and safety.

SBAR

A structured communication tool: Situation, Background, Assessment, Recommendation.

Professional communication

Verbal, nonverbal, written, and electronic communications in healthcare; includes therapeutic, interpersonal, and documentation.

Phases of professional relationships

Orientation, Working, and Termination phases.

Orientation

Phase of establishing trust and setting expectations.

Working

Phase of collaboration and building rapport during care.

Termination

Phase of concluding the professional relationship when goals are met or care ends.

Electronic health records (EHR)

Digital version of patient records used to store and share health information.

Telemedicine

Delivery of clinical care remotely via telecommunications.

Patient monitoring

Ongoing measurement and assessment of a patient’s physiological status.

Standardized terminologies in EHR

Use of consistent vocabularies to ensure clear, interoperable documentation.

Data analytics

Analyzing health data to improve care quality and outcomes.

Sensory perception

Process by which the body detects, interprets, and responds to sensory stimuli.

Risk factors for impaired sensory perception

Aging, diabetes, neurological disorders, medications, trauma, environmental factors like noise or lighting.

Impaired sensory perception signs

Difficulty seeing or hearing, balance changes, social withdrawal, confusion, delayed responses.

Interventions to optimize sensory perception

Assess regularly, promote safety, use assistive devices, optimize environment, educate, and collaborate with specialists.

Neonatal neuro assessment

Assessment of newborn neurological function, including reflexes and reaction to stimuli.

Moro reflex newborn

Neonatal startle reflex present at birth.

Grasp reflex newborn

Neonatal reflex where fingers close around objects placed in the palm.

Root reflex newborn

Rooting reflex: turning the head toward a cheek when stroked.

Suck reflex newborn

Neonatal sucking reflex when something touches the mouth.

Galant reflex newborn

Neonatal reflex involving lateral trunk movements in response to spinal stimulation.

Glasgow Coma Scale

Neurological scale assessing eye (1-4), verbal (1-5), and motor (1-6) responses; total 3-15.

Five rights of delegation

Right task, right circumstances, right person, right direction/communication, right supervision/evaluation