Nursing Assessment and Patient Safety Fundamentals

Comprehensive vocabulary flashcards covering nursing assessment types, data collection methods, safety protocols, and emergency procedures.

Initial Assessment

Performed within a specific time frame after admission to a healthcare agency to establish a baseline for problem identification, reference, and future comparisons.

Problem-Focused Assessment

Determines the status of a specific problem identified in an earlier assessment.

Emergency Assessment

Performed during any physiological or psychological crisis to identify life-threatening problems.

Ongoing Reassessment

Performed minutes to months after the initial assessment to identify new or overlooked critical problems and compare current status to baseline data.

Subjective Data

Information picked up when interacting with the patient, typically what the patient says (talking to patient).

Objective Data

Information that can be seen, smelled, or heard using the 5 senses.

Primary Source

The patient.

Secondary Source

Medical records or family members.

Palpate

Using touch to feel the skin for masses, pain, edema, or swelling.

Percuss

The act of tapping and listening to body sounds.

Auscultate

Listening to body sounds, such as breathing or abdominal sounds, using a stethoscope.

Standard Order of Data Collection

1. Inspect, 2. Palpate, 3. Percuss, 4. Auscultate.

Abdominal Data Collection Order

1. Inspect, 2. Auscultate, 3. Percuss, 4. Palpate.

Maslow's Hierarchy of Needs

A framework used to organize patient data and prioritize needs.

Erikson's Stages of Development

A developmental framework used to organize and understand patient data.

Safety

Freedom from danger, harm, or risks.

Adverse Event

A safety event that results in harm for the patient.

Near Miss (Great Catch)

An event that could have involved the patient but was intercepted.

Sentinel Event

An event not related to the patient's illness or condition that causes death, permanent harm, or temporary harm.

No Harm Event

An event that reaches the patient but results in no harm.

5 Rights of Med Admin

A verification process followed to prevent adverse drug events.

Seizure Precautions

Measures including protecting the head, padding side rails, using loose clothing, placing the patient on their side, and ensuring oxygen and suction are available.

Physical Restraints

Items like ties, vests, or mittens used to restrict a patient's movement.

Chemical Restraints

Sedative medications used to control or restrict a patient's behavior or movement.

Seclusion

Confining a patient to a room as a safety measure.

RACE

Fire planning acronym: R (Rescue/Evacuate patients in danger), A (Alarm), C (Contain by closing doors), E (Extinguish/Evacuate).

PASS Method

The technique used to operate a fire extinguisher.

Exit Safety Checklist

Ensuring the bed is in its lowest position, wheels are locked, the call light and bedside table are within reach, and appropriate bed rails are up.