NURSING PROFESSIONAL PRACTICE & PHYSICAL HEALTH ASSESSMENT FLASHCARDS

100 vocabulary-style flashcards covering nursing practice, ethics, professional roles, nursing process, and physical health assessment concepts from the notes.

Nursing

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, and advocacy.

Nurse Practice Act

A state regulation that defines the legal scope of nursing practice and sets requirements for licensure.

California Board of Registered Nursing (BRN)

State regulatory agency that licenses nurses and enforces nursing practice standards in California.

ANA Code of Ethics

A guiding document based on moral principles that informs professional nursing conduct.

Moral Principles

Core values such as autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity that guide nursing decisions.

Autonomy

The patient’s right to make informed decisions about their own care.

Beneficence

Acting in the best interests of the patient to promote well being.

Nonmaleficence

The obligation to do no harm in providing care.

Justice

Fairness in distributing care and resources.

Fidelity

Faithfulness and keeping promises and commitments to patients.

Veracity

Truthfulness and honesty in communication with patients and colleagues.

Basic Standards of Nursing Care

A set of essential nursing behaviors such as patient centered care, teamwork, EBP, quality improvement, safety, informatics, professionalism, leadership, and communication.

Critical Elements

Key behaviors that define competent nursing practice.

Patient-Centered Care

Care that respects and responds to individual patient preferences, needs, and values.

Teamwork and Collaboration

Working with the interprofessional team to provide safe and effective care.

Evidence-Based Practice (EBP)

Clinical practice based on current best evidence, patient needs, and clinician expertise.

Quality Improvement (QI)

Systematic efforts to improve the safety, effectiveness, and efficiency of care.

Safety

Protection from harm and reduction of exposure to risk in care delivery.

Informatics

Use of information systems and data to support patient care and clinical decision making.

Professionalism

Demonstrating respectful, ethical, responsible behavior as a healthcare professional.

Leadership

Guiding and coordinating care and teams to achieve optimal patient outcomes.

Communication

Clear, accurate, and timely exchange of information among patients and team members.

Accountability

Being answerable for one’s actions and outcomes in patient care.

Responsibility

The duties assigned and carried out in nursing practice; difference from accountability.

Scope of Practice

The legal boundaries of what nurses are allowed to do in a given jurisdiction.

NANDA

A registry of standardized nursing diagnoses used to articulate patient problems.

Nursing Process

A systematic, patient-centered problem solving approach used in nursing care.

Assessment

The collection of data about a patient’s health status through various methods.

Nursing Diagnosis

A clinical judgment about a patient’s response to health problems that can be treated with nursing measures.

Planning

Setting priorities and writing measurable goals and selecting nursing interventions.

Implementation

Carrying out the nursing interventions and providing care.

Evaluation

Measuring progress toward goals and revising the plan as needed.

Subjective Data

Information from the patient or family that cannot be directly observed.

Objective Data

Observations and measurable findings obtained through examination and tests.

AEB

As evidenced by; phrase used in nursing diagnoses to link signs and symptoms to a problem.

Etiology

The cause or contributing factors of a patient problem in a nursing diagnosis.

Nursing Problem

The identified health issue described in the nursing diagnosis.

At Risk

A status indicating a patient that may develop a problem due to risk factors.

Medical Diagnosis vs Nursing Diagnosis

Medical diagnosis describes a disease; nursing diagnosis describes patient responses to health problems.

SMART goals

Specific, Measurable, Attainable, Relevant, Time-based goals for patient outcomes.

Nursing Interventions

Actions carried out to help the patient achieve desired outcomes and goals.

Independent Interventions

Nurse-initiated actions that do not require a physician order.

Dependent Interventions

Interventions that require a physician order or collaboration.

Interdependent Interventions

Collaborative actions involving multiple disciplines.

Delegation

Transferring responsibility for a task to another competent team member while maintaining accountability.

Prioritization

Determining the order in which patient needs should be addressed.

Time Management

Organizing and planning to use time efficiently in patient care.

SBAR

A communication framework: Situation, Background, Assessment, Recommendation.

Nursing Care Plans

Documentation of a patient’s plan of care using assessments, diagnoses, goals, interventions, and evaluation.

Head-to-Toe Physical Examination

Comprehensive exam performed head to toe to assess overall health.

Initial/Complete Exam

A full, initial assessment across all body systems.

Focused/Problem-Focused Exam

A targeted exam directed at a specific problem or symptom.

Inspection

Careful visual examination of the body surfaces.

Auscultation

Listening to internal body sounds with a stethoscope.

Palpation

Using touch to assess texture, temperature, moisture, tenderness, and swelling.

Percussion

Tapping on body surfaces to elicit sounds or vibrations indicating underlying structures.

Vital Signs

Measurement of key physiological parameters that reflect basic functioning: temperature, pulse, respirations, blood pressure, pain, and SpO2.

Temperature

Balance between heat produced and lost; affected by age, time of day, exercise, hormones, stress, and environment; hyperthermia and hypothermia.

Pulse

Wave of blood created by heart contraction; measured in beats per minute; tachycardia and bradycardia.

Respirations

Breathing; measured in breaths per minute; tachypnea and bradypnea.

Blood Pressure

Pressure of blood against arterial walls; systolic measures contraction; diastolic measures relaxation; hypertension and hypotension.

Oxygen Saturation (SpO2)

Measure of the amount of oxygen bound to hemoglobin; influenced by circulation and activity.

Orthostatic Vital Signs

Measurement of BP, HR, and symptoms in supine, sitting, and standing positions to assess hypovolemia.

MEWS (Modified Early Warning System)

Tool to monitor patients and trigger rapid clinical response; scoring based on RR, HR, SBP, conscious level, and temperature.

Pain as Fifth Vital Sign

Pain is assessed routinely as a vital sign, using scales such as VAS, numeric 0–10, or Wong-Baker.

Wong-Baker Faces Scale

Pain scale using facial expressions to rate pain intensity.

Numeric Pain Rating Scale

Scale from 0 to 10 for patient to rate current pain.

Old CART

Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments.

Pain Assessment

Systematic evaluation of onset, location, duration, characteristics, aggravating and relieving factors, and treatments.

Nociception

Physiologic process that conveys tissue damage signals to the CNS.

Transduction

Release of chemical mediators at injury site initiating pain signaling.

Transmission

Conduction of the pain signal from periphery to spinal cord and brain.

Perception

Conscious awareness of pain.

Modulation

Brain signals that modify incoming pain impulses.

Nociceptive Pain

Pain arising from somatic or visceral tissues due to nociceptor activation.

Neuropathic Pain

Pain from damage to peripheral nerves or CNS with burning, shooting, or electric qualities.

Somatic Pain

Localizable pain from bone, joint, muscle, skin, or connective tissue.

Visceral Pain

Pain from internal organs, often cramping or squeezing.

Acute Pain

Pain with rapid onset that varies in intensity and lasts less than 3–6 months.

Chronic Pain

Pain that persists or recurs beyond 3–6 months and affects function.

Pain Threshold

Lowest intensity at which pain is perceived.

Pain Tolerance

Maximum pain intensity or duration a person is willing to endure.

Pain Reaction

Autonomic and behavioral responses to pain.

Nonpharmacological Pain Management

Methods such as cutaneous stimulation, massage, heat/cold, distraction, and relaxation.

TENS

Transcutaneous electrical nerve stimulation; a nonpharmacologic analgesic technique.

Heat and Cold

Thermal therapies used to relieve pain and improve comfort.

Distraction

Cognitive strategies to divert attention away from pain.

NSAIDs

Nonsteroidal anti-inflammatory drugs; e.g., ibuprofen, aspirin; analgesic and anti-inflammatory effects.

Acetaminophen

Analgesic and antipyretic; OTC option with non-inflammatory effect.

Opioids

Analgesics including full agonists, mixed agonist-antagonists, and partial agonists used for moderate to severe pain.

Side Effects of Opioids

Constipation, nausea/vomiting, sedation, respiratory depression, pruritus.

Adjuvant Therapy

Non-analgesic medications that aid pain relief, such as corticosteroids, antidepressants, or antiseizure drugs.

Administration Principles

Scheduling, around-the-clock dosing for constant pain, with consideration of breakthrough pain.

Titration

Dose adjustment based on assessment of analgesia and side effects.

Tolerance

Need for increasing doses to achieve the same effect.

Physical Dependence

Physiologic withdrawal risk if the drug is stopped abruptly.

Addiction

Neurobiological condition with compulsive drug seeking beyond prescribed use.

ADPIE

Five-phase nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation.

Clinical Reasoning

Analysis of a clinical situation to set priorities, form rationales, and act with foresight.

Documentation

Recording nursing actions, patient responses, and care plans to communicate care and outcomes.