Unit 1 Terms

Clinical Judgement

Recognize and interpret client problems, prioritize a response, take action, evaluate outcomes, and modify actions as needed.

Clinical Reasoning

The process of synthesizing knowledge and information from numerous sources and incorporating experience to develop a plan of care for a particular client or case scenario. It requires a reliance on your knowledge and experience to form a conceptual image of a client’s problem and its effective management.

Critical Thinking

Objectively gathering information on a problem or issue recognizing the need for more information evaluating the credibility and usefulness of sources of information recognizing gaps in one’s own knowledge, listening carefully, reading thoughtfully, and separating relevant from irrelevant data and important from unimportant data.

Caring

Thinking and acting in ways that preserve human dignity and humanity. It is specific and relational for each nurse-person encounter.

Nursing Process

Assessment, Diagnosis, Planning Outcomes, Planning Interventions, Implementation, and Evaluation.

Medical Diagnosis

The determination of a disease or condition based on the evaluation of symptoms, medical history, and diagnostic tests. It informs the nursing process and guides patient care.

Nursing Diagnosis

A clinical judgment concerning a human response to health conditions or life processes, which provides the basis for the selection of nursing interventions.

Assessment

The first step in the nursing process, involving the systematic collection, categorization, and recording of data.

Delegation

Nurses (RN) can delegate tasks and assign them to nurse aides, unlicensed personnel (UAP), or Licensed Practical Nurses (LPN). Nurses then validate the data collected, conduct interviews, and complete physical assessments.

Maslow’s Hierarchy of Needs

A five tier pyramid model that organizes human needs. Self actualization, self esteem, love and belonging, safety and security, and physiological needs.

Diagnosing

Second step in the nursing process. Includes analyzing data, drawing conclusions, verifying conclusions, writing the diagnostic statement, and prioritizing the problems.

Planning

Third step in the nursing process. Includes selecting standardized care plans, creating individualized care plans, and identifying outcomes and goals.

Interventions

Fourth step in the nursing process. Includes reviewing diagnoses/outcomes, selecting standardized interventions, and individualizing interventions to meet patient needs.

Outcomes and goals

Personalized or standardized goals or expected outcomes for the patient while they are being cared for in a facility.

Evaluation

Last stage in the nursing process. Evaluations happen with the patient’s progress, efficacy of their care plan, and the quality of care in the healthcare setting.

Vital Signs

Vital signs of physiological processes. Temperature, pulse, respirations, blood pressure, and oxygen saturation.

Temperature

Degree of heat maintained by the body.

Core Temperature

Internal body temperature (95.5-99.8)

Surface Temperature

Lower than core temperature, oral or axillary temp.

Thermoregulation

Process of maintaining a stable temperature. Hypothalamus is the control.

Non-shivering Thermogenesis

A metabolic process where the body creates heat without physical muscle shaking.

Pulse rate

Measure (beats per minute) of the rate of expansion/contraction of the heart. Normal is 60-100 bpm.

Pulse point

Specific locations on the body where the pulse can be felt, such as the wrist or neck. NOTE: Carotid is only done by trained professionals for CPR and for assessing circulation to the head.

Apical Pulse

Pulse point located at the apex of the heart. Is only used when radial pulse is weak or irregular, less than 60bpm, greater than 100bpm, or the patient is taking cardiac medications OR less than 3 years old.

Cardiac Auscultation Points

Locations on the chest where heart sounds can be effectively heard using a stethoscope. These include the aortic, pulmonic, tricuspid, mitral, Erb’s point, and the Xiphoid process.

Respirations

The process of inhaling and exhaling air, which is essential for gas exchange. Normal respiratory rates vary by age and are critical for assessing respiratory health. Typical range is between 12-20 respirations per minute.

Hypoxia

A condition in which there is insufficient oxygen in the tissues, often leading to symptoms such as shortness of breath, confusion, or cyanosis.

Cyanosis

A bluish discoloration of the skin and mucous membranes caused by low levels of oxygen in the blood, often associated with respiratory or circulatory issues.

Blood pressure

The force of blood against the walls of the arteries, typically measured in millimeters of mercury (mmHg). Blood pressure readings are expressed as systolic over diastolic pressure.

Hypotension

A condition characterized by abnormally low blood pressure, which can result in dizziness, fainting, and in severe cases, shock.

Hypertension

A condition characterized by consistently high blood pressure, which can lead to various health problems such as heart disease and stroke.

Comprehensive Assessment

A thorough evaluation of a patient’s health status - includes an interview plus complete head to toe examination.

Focused Assessment

Examination that is focused on the presenting problem. It is system specific and is limited to one body system.

Ongoing Assessment

Type of examination that is performed as needed to assess status and evaluates client outcomes.

Inspection

A visual examination technique used to assess physical conditions by looking at the body and its features. Examples include: skin color, gait, general appearance, and behavior.

Palpation

A technique used in physical examination that involves using the hands to feel the body, assessing texture, temperature, moisture, and movement of tissues, organs, or structures.

Percussion

A technique involving tapping on the surface of the body to evaluate underlying structures. It can provide information about the size, shape, and density of organs.

Ascultation

A technique that involves listening to sounds made by internal organs, typically using a stethoscope to assess the heart, lungs, and intestines.

Pharmacokinetics

The study of how drugs move through the body, including absorption, distribution, metabolism, and excretion.

Drug Interactions

Refer to the ways in which one drug affects the efficacy or toxicity of another drug when administered together. These interactions can influence treatment outcomes and may require adjustments in dosage.

Oral

Administration process of giving medication through the mouth, allowing for absorption in the gastrointestinal tract.

Parenteral

A method of administering medication by injection (Intra/Transdermal, SQ, IM, IV), bypassing the gastrointestinal tract for quicker absorption.

Subcutaneous

A route of administration where medication is injected into the layer of fat beneath the skin, allowing for slow absorption into the bloodstream.

Intramuscular

A method of administering medication directly into a muscle, allowing for faster absorption into the bloodstream compared to subcutaneous administration.

Intravenous

A method of administration where medication is delivered directly into the bloodstream via a vein, allowing for rapid effect.