Foundations Week 1 and 2

Comprehensive vocabulary flashcards covering the nursing process, professional documentation, infection control, and personal hygiene techniques based on the foundations of professional nursing practice.

Nursing Process

A systematic, dynamic, interpersonal, and outcome-oriented framework used by nurses to provide universally applicable care.

Objective Data

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them, such as a temperature of $100.4^{\circ}F$.

Subjective Data

Information perceived only by the affected person, such as reporting pain, feeling dizzy, or feeling anxious.

NANDA Nursing Diagnosis

The first part of a nursing diagnosis that identifies what is unhealthy about the client and addresses the human response.

Etiology

The component of a nursing diagnosis, identified as 'related to' (r/t), that pinpoint factors maintaining the unhealthy state.

Defining Characteristics

The subjective and objective data that signal the existence of a problem, identified in a diagnosis as 'as evidenced by' (AEB).

SMART Goals

An acronym for writing expected client outcomes: Specific, Measurable, Attainable, Relevant, and Time-bound.

Maslow's Hierarchy of Human Needs

A framework developed by psychologist Abraham Maslow used to establish priorities, beginning with physiological needs like oxygen, nutrition, and fluids.

Nurse-initiated Interventions

Independent nursing actions performed without a physician's order, such as protocols and standing orders.

Delegation 'EAT' Acronym

A mnemonic stating a nurse cannot delegate tasks involving Evaluation, Assessment, and Teaching.

Electronic Health Record (EHR)

A digital legal record of all pertinent interactions with a client, facilitating quality, evidence-based care.

Charting by Exception

A documentation method that identifies normal findings and allows for selective documentation of abnormal findings.

SOAP format

A problem-oriented medical record documentation style consisting of Subjective data, Objective data, Assessment, and Plan.

PIE format

A problem-oriented medical record documentation style consisting of Problem, Intervention, and Evaluation.

DAR format

A focus charting format consisting of Data, Action, and Response.

ISBARR

A reporting format used for handoffs and professional communication between healthcare team members.

Purposeful Rounding

A proactive practice where nurses greet clients and assess the 4 P’s: Pain, Personal needs (toileting), Positioning, and Fall prevention.

Infectious Agent

The causative component of the infection cycle, including bacteria, viruses, fungi, parasites, and prions.

Aerobic Bacteria

Bacteria that require oxygen to live.

Anaerobic Bacteria

Bacteria that can live without oxygen.

Endemic

An infectious agent that occurs with predictability in one specific region or population.

Prodromal Stage

The stage of infection where the person is most infectious, characterized by vague and nonspecific signs of disease.

Medical Asepsis

Also known as clean technique, these activities reduce the number of pathogens and include hand hygiene and wearing gloves.

Surgical Asepsis

Also known as sterile technique, these activities keep an area free from all microorganisms, used for procedures like catheterization.

Transient Flora

Bacterial flora attached loosely on the skin that can be removed with relative ease through hand hygiene.

CAUTI

A targeted health care-associated infection referring to Catheter-associated urinary tract infection.

Standard Precautions

Precautions used in the care of all hospitalized clients regardless of diagnosis, applying to blood, body fluids, nonintact skin, and mucous membranes.

Transmission-Based Precautions

Precautions used for known or suspected infections spread by airborne, droplet, or contact routes.

Stomatitis

An inflammation of the oral mucosa.

Canthus

The corner of the eye; during eye care, cleaning should proceed from the inner to the outer canthus.

Ecchymosis

A discoloration of the skin resulting from bleeding underneath, typically caused by bruising.

Perineum

The area of the body between the anus and the vulva or scrotum.

Prepuce

The foreskin of the penis.

HS Care

Hygiene care provided at the 'Hour of Sleep' before a client retires, including toileting, washing, and oral care.

PRN Care

Hygiene measures offered 'as needed,' such as providing oral care every 2 hours or changing linens for diaphoretic clients.