NURS233 Exam 3 Nursing Process & Informatics

Comprehensive vocabulary flashcards covering the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation), documentation standards, and nursing informatics.

Nursing Assessment

The systematic and continuous collection, analysis, validation, and communication of data that reflects a patient’s health status and responses to illness.

Comprehensive (Initial) Assessment

A full database assessment performed on admission to a healthcare facility to establish a baseline.

Focused Assessment

An assessment focused on a specific problem, which may be an ongoing issue or a new concern.

Emergency Assessment

A priority assessment conducted during life-threatening situations to identify the most critical problems.

Time-lapsed Assessment

A reassessment performed to compare a patient's current status to a previously obtained baseline.

Triage Assessment

An assessment used to determine the urgency and severity of a patient's condition, commonly used in emergency rooms or over the phone.

Objective Data (Signs)

Observable and measurable data that can be seen, heard, or felt by others, such as a blood pressure of $120/80 ext{ mmHg}$.

Subjective Data (Symptoms)

Data based on the patient’s personal experience that cannot be measured directly, such as reports of pain, dizziness, or feeling tired.

Inspection

A method of physical assessment involving deliberate, purposeful, and systematic observation.

Palpation

An assessment method using touch to evaluate temperature, texture, moisture, turgor, and vibrations.

Percussion

The act of tapping or striking the body to produce sound, helping to assess the location and density of underlying structures.

Auscultation

The process of listening to internal body sounds, such as heart, lung, or bowel sounds, usually with a stethoscope.

Nursing Diagnosis

A clinical judgment focusing on the patient's response to health conditions that nurses are licensed to treat independently.

Medical Diagnosis

A diagnosis that focuses on specific diseases or pathologies and is managed primarily by a physician.

Collaborative Problems

Certain physiologic complications that require both nursing and medical interventions to monitor and treat.

Etiology

The cause of a problem, identified in a nursing diagnosis using the phrase "related to."

Maslow’s Hierarchy of Needs

A method to rank patient needs from highest priority to lowest: Physiologic (Airway, Breathing, Circulation), Safety, Love/belonging, Self-esteem, and Self-actualization.

Outcome

A specific, measurable, patient-centered expected result used to evaluate the effectiveness of the care plan.

Direct Care

Hands-on nursing actions performed in physical contact with the patient, such as administering medication.

Indirect Care

Nursing actions performed away from the patient but on their behalf, such as updating a care plan or interdisciplinary collaboration.

Alfaro Rule

A clinical reasoning guide for implementation: Assess → Reassess → Revise → Record.

Five Rights of Delegation

The requirements for safe delegation: Right task, Right circumstances, Right person, Right communication, and Right supervision/evaluation.

Cognitive Outcome

An evaluation of a patient's increased knowledge, such as a patient explaining the purpose of their blood pressure medication.

Psychomotor Outcome

An evaluation of a patient's achievement of new skills, such as demonstrating the correct technique for an insulin injection.

Affective Outcome

An evaluation of changes in a patient's values, beliefs, or attitudes, such as expressing a willingness to follow a diet.

Physiologic Outcome

An evaluation of physical changes in the patient's body status, such as a temperature change to $98.6 ext{ }^ ext{o} ext{F}$.

Charting by Exception (CBE)

A shorthand documentation method where only abnormal or significant findings are recorded, assuming normal findings unless otherwise noted.

PIE Charting

A documentation format that organizes information by Problem, Intervention, and Evaluation.

SBAR

An acronym for Situation, Background, Assessment, Recommendation; used for shift handoffs and professional reporting.

Nursing Informatics

A specialty that integrates nursing science, information science, and computer science to manage data and support nursing practice.

Interoperability

The ability of different health information systems and software applications to communicate and exchange data accurately.

Telehealth

The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient education, and health administration.

Telemedicine

The remote delivery of clinical services, such as a provider assessing a patient's symptoms via a video visit.

HIPAA

A federal law that protects patient privacy and ensures the confidentiality of health information.

System Usability

A measure of how easy and efficient a health information system is for clinicians to use.