Unit 1 Key Terms

Assessment

The systematic collection, validation, organization, and documentation of patient data to identify actual or potential health problems.

Auscultation

The use of hearing, typically with a stethoscope, to assess internal body sounds such as breath, heart, and bowel sounds.

Collaborative nursing interventions

Interventions carried out by the nurse in coordination with other members of the interprofessional health care team.

Cue

A piece of subjective or objective data that can be interpreted as significant to the patient’s health status.

Dependent nursing interventions

Actions that require a provider’s prescription or order before the nurse can implement them.

Diagnosis label

The standardized name of a nursing diagnosis that describes the patient response or problem identified by the nurse.

Direct care

Hands-on nursing care provided through direct interaction with the patient.

Etiology

The related cause or contributing factor of a nursing diagnosis, often written as the 'related to' portion of the diagnosis statement.

Evaluation

The final phase of the nursing process in which the nurse determines whether expected outcomes have been achieved.

Health history

A comprehensive collection of subjective data about the patient’s past and present health status, habits, medications, and risk factors.

Implementation

The phase of the nursing process in which planned nursing interventions are carried out.

Independent nursing interventions

Nursing actions the nurse is licensed to initiate based on clinical judgment without a provider’s order.

Indirect care

Nursing actions performed away from the patient but on the patient’s behalf, such as documentation, collaboration, and care coordination.

Inspection

The deliberate visual examination of the patient for normal and abnormal findings.

Long-term goals

Expected outcomes that require a longer period of time to achieve, often days, weeks, or months.

Nursing diagnosis

A clinical judgment about a human response to actual or potential health conditions or life processes that nurses are licensed to treat.

Nursing process

A systematic, patient-centered framework for care consisting of assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

Objective data

Observable, measurable, and verifiable findings obtained through assessment.

Outcome identification

The phase in which measurable, patient-centered goals and expected outcomes are established.

Palpation

The use of touch to assess temperature, texture, tenderness, moisture, masses, and organ location.

Patient interview

A purposeful therapeutic conversation used to obtain health-related information from the patient.

Percussion

Tapping the body to produce sounds that help determine the density, size, and location of underlying structures.

Planning

The phase of the nursing process in which priorities are established and interventions are selected to achieve patient outcomes.

Primary data

Information obtained directly from the patient.

Problem-focused nursing diagnoses

Diagnoses that describe existing patient problems supported by defining characteristics.

Related factors

Conditions or causes that contribute to a nursing diagnosis and guide nursing interventions.

Risk factors

Conditions or circumstances that increase the patient’s vulnerability to developing a problem.

Risk nursing diagnoses

Diagnoses describing human responses the patient is more vulnerable to developing, even though the problem is not yet present.

Secondary data

Information obtained from sources other than the patient, such as family, records, or other team members.

Short-term goals

Expected outcomes that can usually be achieved in a short time, often within hours or days.

Signs

Objective evidence of disease or dysfunction observed by others.

Subjective data

Information reported by the patient that cannot be directly measured by others.

Symptoms

Subjective indicators of disease or altered health status experienced and described by the patient.

Accommodation

The ability of the eye to adjust focus for objects at varying distances by changing lens shape.

Adventitious breath sounds

Abnormal breath sounds, such as crackles, wheezes, rhonchi, or stridor, that indicate altered airway or lung function.

Albinism

An inherited condition characterized by absent or markedly reduced melanin production in the skin, hair, and eyes.

Alopecia

Hair loss from the scalp or body that may be localized or generalized.

Atelectasis

Collapse of alveoli resulting in reduced or absent gas exchange in part of the lung.

Borborygmi

Loud, gurgling bowel sounds produced by the movement of gas through the intestines.

Bruit

An abnormal blowing or swishing sound heard over a blood vessel, suggesting turbulent blood flow.

Capillary refill

The time required for color to return to a blanched nail bed or skin after pressure is released, reflecting peripheral perfusion.

Cardiac murmurs

Abnormal heart sounds caused by turbulent blood flow through the heart valves or chambers.

Cataracts

Opacity of the lens of the eye that interferes with vision.

Cerumen

Earwax produced in the external auditory canal that helps protect and lubricate the ear.

Chief complaint

The primary reason the patient is seeking care, usually stated in the patient’s own words.

Clinical manifestations

Observable and reported signs and symptoms associated with a disease or condition.

Comorbid

Referring to the presence of one or more additional diseases or conditions occurring with a primary condition.

Consistency

The degree of firmness or density of tissue, stool, masses, or other assessed structures.

Cyanosis

Bluish discoloration of the skin or mucous membranes due to decreased oxygenation.

Deep vein thrombosis (DVT)

Formation of a thrombus in a deep vein, most commonly in the lower extremities.

Dysrhythmia

An abnormal cardiac rhythm caused by altered electrical conduction in the heart.

Ecchymosis

A large area of discoloration caused by bleeding into the subcutaneous tissue.

Edema

An abnormal accumulation of fluid in the interstitial spaces.

Epistaxis

Bleeding from the nose.

Erythema

Redness of the skin caused by capillary dilation, often associated with inflammation or irritation.

Excoriation

Superficial loss of skin due to scratching, rubbing, or abrasion.

Focused assessment

A targeted assessment of a specific problem, body system, or complaint.

Guarding

Voluntary or involuntary tensing of abdominal muscles to protect inflamed organs from palpation.

Jaundice

Yellow discoloration of the skin, sclera, and mucous membranes caused by elevated bilirubin.

Nystagmus

Involuntary rhythmic oscillation of the eyes.

Pallor

Abnormal paleness of the skin or mucous membranes, often associated with decreased perfusion or anemia.

Paresthesia

Abnormal sensation such as numbness, tingling, or “pins and needles.”

Physical assessment

A systematic head-to-toe or focused examination of the body using inspection, palpation, percussion, and auscultation.

Pruritus

Itching.

Ptosis

Drooping of the upper eyelid.

Pulse deficit

The difference between the apical pulse rate and the peripheral pulse rate, indicating not all heartbeats are perfusing peripherally.

Purpura

Purple discolorations on the skin caused by bleeding underneath the skin, larger than petechiae.

Purulent

Containing pus, usually indicating infection.

Rebound tenderness

Pain produced when pressure is quickly released from the abdomen, suggesting peritoneal irritation.

Stenosis

Abnormal narrowing of a body opening, passage, or vessel.

Tactile fremitus

Palpable vibration on the chest wall produced by speaking.

Thrill

A palpable vibration over the heart or blood vessel caused by turbulent blood flow.

Tinnitus

Perception of ringing, buzzing, or other sounds in the ears without an external source.

Turgor

Skin elasticity, often assessed to evaluate hydration status.

Vertigo

A sensation of spinning or movement, usually associated with vestibular dysfunction.

Vitiligo

Patchy loss of skin pigmentation due to destruction of melanocytes.

Chemical restraint

A medication used to restrict a patient’s behavior or freedom of movement and not used as standard treatment for the patient’s condition.

Falls

Unintended descents to the floor or another lower surface, with or without injury.

Physical restraint

Any manual method, physical device, material, or equipment attached to or near the patient that the patient cannot easily remove and that restricts movement.

Safety

Protection from physical and psychological harm within the health care environment.

Unintentional injuries

Injuries that occur without deliberate intent, such as falls, burns, poisonings, or motor vehicle trauma.