Nursing Process, Critical Thinking, Care Management, and Infection Control

Vocabulary flashcards generated from lecture material covering fundamental nursing processes, critical thinking skills, diagnostic statements, client care models, delegation guidelines, and infection control principles.

Nursing Process

The standard of practice in nursing consisting of 6 phases that guides all nursing actions and provides goal-directed, client-centered care.

Reflective Journaling

A tool for developing critical thinking skills by defining and expressing clinical experiences in one's own words.

Concept Mapping

A visual representation of patient problems and interventions that shows their relationships to one another.

Critical Thinking

The skill of learning to analyze and interpret data to solve a problem and achieve a desired outcome, encompassing questioning, analysis, synthesis, interpretation, inference, reasoning, intuition, application, and creativity.

Assessment

The point of entry in an ongoing nursing process involving the systematic gathering, validating, organizing/clustering, and recording of physical, mental, spiritual, socioeconomic, and cultural data.

Clinical Reasoning

The mental process used when analyzing all the data of a clinical situation to make decisions based on nursing knowledge and relevance.

Clinical Judgment

Clinical reasoning across an expanse of time that happens repetitively and improves with practice, serving as the visible outcome of critical thinking and decision making.

NANDA-I

North American Nursing Diagnosis Association International, which currently approves 235 nursing diagnoses as the basis for selecting nursing interventions.

Medical Diagnosis

A diagnosis that identifies a disease or pathology with the primary goal to cure (e.g., Myocardial Infarction or Appendicitis).

Nursing Diagnosis

A clinical judgment that identifies a patient's response to disease or pathology, with the primary goal of directing care to meet patient needs.

Actual (Problem-Focused) Nursing Diagnosis

A three-part diagnostic statement based on a problem present at assessment, consisting of the nursing diagnosis label, related factors (R/T), and defining characteristics (s/s).

Potential (Risk) Nursing Diagnosis

A two-part diagnostic statement for a problem that may occur, written as 'Risk for [problem] related to [risk factors or s/s]'.

Wellness (Health Promotion) Nursing Diagnosis

A one-part diagnostic statement representing a transition from one level of wellness to a higher level of wellness, written as 'Readiness for enhanced [status]'.

Essential Goals

Care planning goals directed by the nursing diagnosis problem/label; at least one must be stated for every nursing diagnosis to demonstrate resolution or improvement.

Nonessential Goals

Care planning goals that are directed by the etiology of the nursing diagnosis rather than the problem label.

Independent Nursing Interventions

Nurse-initiated actions that do not require an order from another health care professional.

Dependent Nursing Interventions

Nursing actions that require an order from another health care professional.

Collaborative Interventions

Interdependent nursing actions that require overlapping knowledge and input from multiple healthcare disciplines.

Reflection-in-action

The evaluative process where a nurse continuously examines results by gathering subjective and objective data while reviewing clinical knowledge and previous patient experiences.

Transformational Leadership

A leadership approach initiated by nurse executives to build an empowered nursing team.

TEEAMS Approach

An acronym for an empowered team-building model standing for Time, Empowerment, Enthusiasm, Appreciation, Management, and Support.

Total Patient Care

A care delivery model where a registered nurse works directly with the patient, family, and health care team and retains shift responsibility for client care.

Case Management

A collaborative process of assessing, planning, facilitating, and advocating for options to meet health needs, often coordinated by an Advanced Practice Nurse (APN).

Decentralized Management

An organizational structure where decision-making occurs at the staff level, encompassing responsibility, autonomy, authority, and accountability.

SMART Goals

A framework for goal setting ensuring goals are Specific, Measurable, Attainable, Realistic, and Timely.

SBAR

A structured communication tool standing for Situation, Background, Assessment, and Recommendation used to organize clinical handoffs.

SOAP Note

A structured nursing documentation format standing for Subjective, Objective, Assessment, and Plan.

Delegation

The process of one person assigning specific tasks to another person within standardized guidelines and scope of practice.

Five Rights of Delegation

The standards for safe delegation consisting of Right Task, Right Circumstance, Right Person, Right Direction, and Right Supervision.

Team Nursing

A care model that pairs two or more nurses together as a team to share responsibilities and care for a group of clients.

Chain of Infection

The sequence required for infection to occur: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Prion

An infectious agent that lacks DNA/RNA and causes neurological damage.

Reservoir

The habitat where an infectious agent lives, grows, and reproduces or replicates itself.

Portal of Exit

The pathway or means by which an infectious agent leaves its reservoir.

Portal of Entry

Any body orifice or skin opening that allows an infectious agent to replicate or its toxin to act.

Direct Contact Transmission

The movement of microorganisms directly from an infected person to another person without an intermediate object or person.

Indirect Contact Transmission

The movement of microorganisms from an infected person to another person via a intermediate contaminated object or person.

Droplet Transmission

Transmission occurring when respiratory tract droplets travel through the air into the mucosa of a host.

Airborne Transmission

Transmission occurring when small infectious particulates travel into the airspace of another person.

Nonspecific Immunity

Immunity involving phagocytes (neutrophils and macrophages) that engulf and destroy microorganisms during an inflammatory response.

Specific Immunity

Immunity involving antibodies (immunoglobulins) and lymphocytes that target and destroy specific infectious agents.

Multidrug-Resistant Organisms (MDROs)

Organisms that are resistant to multiple antibiotics, such as MRSA (Methicillin-resistant Staphylococcus aureus).

Local Infection

An infection confined to a single area of the body, manageable with topical or oral antibiotics.

Systemic Infection

An infection that originates locally and spreads into the bloodstream to affect the entire body.

Medical Asepsis

Clean technique aimed at eliminating and preventing the presence of disease-causing microorganisms.

Surgical Asepsis

Sterile technique that eliminates all microorganisms from an area or object during sterile procedures.

Standard Precautions

Infection control practices applied to all clients regardless of their known infection status.

Health Care-Associated Infections (HAIs)

Infections acquired during healthcare delivery, key types being CLABSIs, CAUTIs, SSIs, and VAPs.