Nursing Practice: Documentation, Vital Signs, and Infection Control

Comprehensive vocabulary flashcards covering nursing documentation, electronic health records, vital sign assessment, and infection control principles.

Health Care Documentation

Any written or electronically generated information about a patient that describes the patient, the patient's health, and the care and services provided, including the dates of care.

Medical Record

A legal document containing comprehensive information about a patient's health care encounter, as well as demographic, administrative, and clinical data, which serves as a primary communication tool and clinical data archive.

Electronic Medical Record (EMR)

A record of one episode of care, such as a single inpatient hospital stay or an outpatient appointment.

Electronic Health Record (EHR)

A longitudinal record of health that includes information from inpatient and outpatient episodes of health care from one or more care settings.

Computerized Provider Order Entry (CPOE)

A feature that allows clinicians to enter medical orders into a computer system that transmits them directly to the appropriate department.

Problem-Oriented Medical Record (POMR)

A documentation framework that integrates charting from the entire interprofessional care team into the same section of the record based on patient problems.

PIE Note

A problem-oriented charting format organized into Problem (P), Intervention (I), and Evaluation (E).

APIE Note

A documentation format that adds Assessment (A), combining subjective and objective data, to the problem, intervention, and evaluation (PIE) structure.

SOAP Note

A structured format used to chart Subjective data (S), Objective data (O), Assessment (A), and Plan (P).

DAR Note

A focus charting format that organizes entries into Data (D) collected about the patient's problem, Action (A) initiated, and the patient's Response (R).

Charting by Exception (CBE)

A documentation method that records only abnormal or significant findings, assuming pre-established standard norms for all other parameters.

Medication Administration Record (MAR)

A list of ordered medications including dosages, routes, and administration times, on which the nurse signs or initials medications given or not given.

Bar-Coded Medication Administration (BCMA)

A safety system where a nurse uses a portable scanner to scan the patient's identification wristband and the medication before administration to prevent errors.

Sentinel Event

A patient safety event that results in death, permanent harm, severe temporary harm, or requires interventions to sustain life, signaling the need for immediate investigation.

SBAR

A standardized situation-briefing communication framework structured around Situation (S), Background (B), Assessment (A), and Recommendation (R).

Incident Report

A nonjudgmental, objective, factual risk-management report completed immediately after an unusual and unexpected event involving a patient, visitor, or staff member; it is not part of the patient's permanent medical record.

Vital Signs

A set of physiologic measurements monitoring body systems, consisting of body temperature (T), pulse (P), respirations (R), and blood pressure (BP), typically reported alongside pulse oximetry ($SpO_2$).

Afebrile

The condition of maintaining a normal body temperature, typically within the range of $36.4^\circ\text{ C}$ to $37.6^\circ\text{ C}$ ($97.6^\circ\text{ F}$ to $99.6^\circ\text{ F}$).

Core Temperature

The internal temperature of deep tissues within the body, which is regulated to remain relatively constant.

Thermoregulation

The physiologic and behavioral mechanisms governed by the hypothalamus that regulate the balance between heat production and heat loss.

Hypothermia

An abnormally low core body temperature resulting from prolonged exposure to cold without adequate protective measures.

Hyperthermia

An elevation in body temperature occurring when the body produces or absorbs more heat than it can dissipate.

Heatstroke

A dangerous health emergency caused by prolonged sun or heat exposure that overwhelms the body's heat-loss mechanisms, characterized by high core temperature, delirium, and hot, dry skin without sweating.

Heat Exhaustion

A condition resulting from extreme environmental heat exposure that leads to profuse diaphoresis and consequent excessive water and electrolyte deficit.

Temporal Artery Thermometer (TAT)

A handheld infrared device scanned across the forehead to measure heat emitted by the temporal artery while correcting for ambient temperature.

Tympanic Thermometer

A battery-powered instrument that measures infrared radiation emitted from the tympanic membrane using a disposable probe placed in the ear canal.

Apical Pulse

A central pulse auscultated with a stethoscope over the apex of the heart at the point of maximal impulse (PMI), located at the fifth intercostal space at the left midclavicular line.

Tachycardia

An abnormally elevated heart rate exceeding $100\text{ bpm}$ in an adult.

Bradycardia

A slow heart rate of less than $60\text{ bpm}$ in an adult.

Pulse Deficit

A condition in which the radial pulse is slower than the apical pulse because weak or ineffective cardiac contractions fail to pump blood to peripheral vessels.

Dysrhythmia

An irregular heartbeat rhythm caused by early, late, or missed contractions (also termed an arrhythmia).

Doppler Ultrasound Unit

A handheld instrument that uses ultrasound waves and transmission gel to detect and amplify pulse waves that cannot be palpated manually.

Eupnea

Normal, quiet, effortless respiration with a rate between $12\text{ and }20\text{ breaths/min}$ in an adult.

Tachypnea

An abnormally rapid respiratory rate exceeding $24\text{ breaths/min}$ in an adult.

Bradypnea

An abnormally slow respiratory rate of less than $10\text{ breaths/min}$ in an adult.

Dyspnea

Difficult, labored, or painful breathing, often associated with rapid shallow breaths and accessory muscle usage.

Orthopnea

Difficulty in breathing when in a flat, recumbent position that is relieved by sitting or standing upright.

Cyanosis

A bluish discoloration of the skin and mucous membranes resulting from decreased oxygen levels in arterial blood.

Oxygen Saturation ($SpO_2$)

The percentage of hemoglobin combined with oxygen in arterial blood, normally between $95\%$ and $100\%$, measured noninvasively by pulse oximetry.

Systolic Pressure

The peak blood pressure exerted against the arterial walls during the contraction phase of the left ventricle.

Diastolic Pressure

The lowest pressure exerted against the arterial walls when the ventricles of the heart are at rest.

Pulse Pressure

The mathematical difference between the systolic and diastolic blood pressure values.

Orthostatic Hypotension

A sudden reduction of at least $20\text{ mm Hg}$ in systolic pressure or $10\text{ mm Hg}$ in diastolic pressure (or a heart rate increase of $20\text{ bpm}$) within 1 to 3 minutes of moving from a supine to sitting or standing posture.

Hypertension

A sustained elevation in blood pressure, categorized as stage 1 ($130\text{--}139\text{ mm Hg}$ systolic or $80\text{--}89\text{ mm Hg}$ diastolic) or stage 2 ($\ge 140\text{ mm Hg}$ systolic or $\ge 90\text{ mm Hg}$ diastolic).

Korotkoff Sounds

The vascular sounds auscultated over an artery during indirect blood pressure measurement with a sphygmomanometer, divided into five phases.

Auscultatory Gap

The temporary absence of Korotkoff sounds noted in some patients after the initial systolic sound, occurring during the latter part of phase I and phase II.

Asepsis

The condition of freedom from disease-causing contamination and the clinical techniques employed to prevent infection.

Normal Flora

A group of benign microorganisms residing on or inside the skin, mucous membranes, and gastrointestinal tract that inhibit colonization by pathogenic microbes as the first line of defense.

Inflammatory Response

The body's second line of defense; a localized physiologic response to cellular injury characterized by capillary dilation, leukocyte infiltration, redness, heat, pain, and edema.

Antigen

Any substance, living or nonliving, that provokes an adaptive immune response upon recognition by the host immune system.

Humoral Immunity

An adaptive immune defense mediated by B lymphocytes producing specific circulating antibodies (immunoglobulins) in response to antigens.

Cellular Immunity

An adaptive immune defense mediated by T lymphocytes (such as cytotoxic T cells and helper T cells) that directly attack foreign, nonself, or infected cells.

Health Care–Associated Infections (HAIs)

Infections acquired by patients while receiving medical or surgical treatment within a health care facility.

Medical Asepsis

Clean technique; practices such as handwashing, gloving, gowning, and disinfecting designed to reduce the number, growth, and transmission of pathogenic microorganisms.

Surgical Asepsis

Sterile technique; meticulous procedures used to eliminate all microorganisms, including bacterial spores, from objects or fields that invade sterile body cavities or break skin.

Disinfection

A chemical or physical process that destroys all pathogenic vegetative microorganisms except bacterial spores on inanimate objects.

Sterilization

A physical or chemical process that completely destroys all microbial life, including bacterial spores, on equipment and supplies.

Standard Precautions

Comprehensive infection prevention practices used for all patients regardless of diagnosis whenever contact with blood, body fluids, nonintact skin, or mucous membranes is possible.

Protective Isolation

Specialized precautions (including positive-pressure airflow rooms and HEPA filtration) designed to shield severely immunocompromised patients from environmental pathogens.

N95 Respirator

A specialized, fitted particulate filtration mask designed to protect the wearer against airborne particles and small droplets under airborne transmission precautions.