Clinical Studying

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Assessment

systematic collection of patient data

Diagnosis

identifying patient health problems

Care Plan

individualized plan for patient care

Intervention

nursing action to improve patient outcomes

Evaluation

checking if interventions were effective

Documentation

recording patient data and care

Vital Signs

pulse blood pressure respiration temperature oxygen saturation pain

Asepsis

keeping environment free from microorganisms

Standard Precautions

basic infection prevention practices

Transmission-Based Precautions

specific infection control depending on pathogen

Hand Hygiene

cleaning hands with soap or sanitizer

PPE

personal protective equipment like gloves mask gown goggles

Fall Risk

likelihood of patient falling

Informed Consent

patient’s permission after explanation of procedure

Advance Directive

legal document stating patient’s wishes for care

HIPAA

law protecting patient privacy and health information

Triage

prioritization of patients by urgency of condition

Scope of Practice

defines tasks a nurse is legally allowed to perform

Delegation

assigning tasks to others while retaining accountability

SBAR

communication method Situation Background Assessment Recommendation

Charting by Exception

documenting only abnormal findings

Primary Survey

initial ABCDE assessment Airway Breathing Circulation Disability Exposure

Secondary Survey

detailed head-to-toe assessment

ADL

activities of daily living

I&O

intake and output

DNR

do not resuscitate

CPR

cardiopulmonary resuscitation

OOB

out of bed

Bedrest

restriction of patient to bed

ROM

range of motion exercises

Ambulation

process of helping patient walk

Transfer

moving a patient from one surface to another

Turn Schedule

plan for repositioning patient to prevent pressure injuries

Skin Integrity

condition of patient’s skin

Pressure Ulcer

injury from prolonged pressure on skin

Shearing

skin damage from sliding movement

Friction

rubbing force that damages skin

Wound Dressing

cleaning and covering wounds

Steri-Strips

adhesive strips to approximate wound edges

Sutures

stitches to close wounds

Staples

metal clips to close wounds

Drainage

fluid leaving wound

Serous

clear wound drainage

Sanguineous

bloody wound drainage

Serosanguinous

pink watery drainage

Purulent

pus-filled drainage

Debridement

removal of dead tissue

Granulation Tissue

new tissue forming in healing wound

Evisceration

organs protruding through surgical incision

Dehiscence

wound reopening after closure

Catheterization

inserting tube into bladder

Indwelling Catheter

catheter left in bladder for continuous drainage

Straight Catheter

catheter used once to empty bladder

Urinary Retention

inability to empty bladder

Urinary Incontinence

inability to control urination

Oliguria

low urine output

Anuria

absence of urine output

Polyuria

excessive urine output

Hematuria

blood in urine

Pyuria

pus in urine

Urinalysis

lab test of urine sample

Specific Gravity

measure of urine concentration

NG Tube

tube through nose into stomach

G Tube

tube inserted directly into stomach

PEG Tube

percutaneous endoscopic gastrostomy tube

Enteral Feeding

providing nutrition through GI tube

TPN

total parenteral nutrition through IV

Residual Volume

fluid remaining in stomach after feeding

Suctioning

removing secretions from airway

Oral Suctioning

clearing secretions from mouth

Nasopharyngeal Suctioning

suctioning secretions from nose or throat

Endotracheal Suctioning

suctioning through artificial airway

Oxygen Therapy

administration of supplemental oxygen

Nasal Cannula

tubing delivering oxygen to nostrils

Simple Face Mask

mask covering nose and mouth for oxygen delivery

Non-Rebreather Mask

mask with reservoir for high O2 concentration

Venturi Mask

precise oxygen delivery device

Intubation

insertion of tube into trachea

Extubation

removal of breathing tube

Tracheostomy

surgical opening in trachea for airway

Pulse Oximetry

measurement of oxygen saturation

Capnography

measurement of exhaled CO2

ABG

arterial blood gas test

pH

measure of blood acidity or alkalinity

PaO2

partial pressure of oxygen in arterial blood

PaCO2

partial pressure of carbon dioxide in blood

HCO3

bicarbonate concentration in blood

Hypoxemia

low oxygen in blood

Hypercapnia

high carbon dioxide in blood

Hypocapnia

low carbon dioxide in blood

Aspiration

inhalation of food liquid or vomit into airway

Bronchospasm

sudden narrowing of airway

Atelectasis

collapsed lung alveoli

Pneumothorax

air in pleural space causing lung collapse

Hemothorax

blood in pleural space

Pleural Effusion

fluid in pleural space