NR224 Unit1 Clinical Reasoning and Infection Control

Clinical Reasoning

The process of collecting and analyzing information to make clinical judgments.

SOAP Note

A standardized format for narrative nursing documentation that includes Subjective data, Objective data, Assessment, and Plan.

Electronic Medical Record (EMR)

Documentation of a single encounter between an individual and a healthcare professional.

Electronic Health Record (EHR)

A longitudinal record of an individual's encounters with multiple health professionals.

Concept Mapping

A visual representation of clinical reasoning and clinical judgment to see relationships between data.

Infection Control

Practices to prevent the spread of infections within healthcare settings.

Personal Protective Equipment (PPE)

Clothing and equipment worn to protect health care workers from infection.

Hand Hygiene

The process of cleaning hands to remove pathogens, a key aspect of infection control.

Chain of Infection

The process by which an infectious agent passes from a reservoir to a susceptible host.

Antiseptic Hand Sanitizer

A liquid used instead of soap and water to reduce infectious agents on the skin.

Isolation Precautions

Protocols used to prevent the spread of infections during patient care.

Correct Documentation

Recording information factually, objectively, and accurately in medical records.

Gown

Protective clothing used to cover the caregiver's arms and body from contamination.

EMR vs EHR

EMR is visit-specific; EHR is a comprehensive record over time.

Sterile Technique

Practices that ensure the absence of all microorganisms, used in specific medical procedures.

Surgical Asepsis

Another term for sterile technique, ensuring no microorganisms are present.

Standards of Care

Expected levels of performance in nursing documentation and patient care.

Droplet Precautions

Infection control measures for diseases transmitted by droplets larger than 5 microns.

Airborne Precautions

Measures to prevent transmission of infectious agents that remain suspended in the air.

Direct Contact Transmission

Transmission through physical contact with an infected person.

Infectious Agent

Any organism capable of causing disease, including bacteria, viruses, and fungi.

Risk for Infection Diagnosis

A nursing diagnosis indicating patients at high risk for developing infections.

Assessment

The systematic collection of data about a patient’s health status.

Documentation Errors

Mistakes in recording patient information that must be corrected properly.

PPE Guidelines

Protocols for the proper use and removal of personal protective equipment.

Causative Agent

The microorganism responsible for causing a disease.

Healthcare-associated infections (HAIs)

Infections acquired while receiving treatment for other conditions in a healthcare setting.

Serous Exudate

Clear, thin, and watery fluid often seen in wound healing.

Purulent Exudate

Thick, opaque, and often foul-smelling fluid associated with infection.

Chain of Infection Components

Includes pathogen, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Clinical Appearance

Observable signs and symptoms of a patient's condition.

Concept Mapping Steps

Collecting data, identifying health concerns, placing sub-concepts, and reviewing connections.

Patient Discharge Planning

The process of planning for a patient's care after leaving the healthcare facility.

Incidence Report

Documentation of events not consistent with routine care procedures.

Surgical Scrub

A special handwashing procedure to remove pathogens before surgery.

Isolation Precautions Examples

Used for conditions like MRSA, C-diff, and varicella.

Hygiene Practices

Methods to maintain cleanliness and prevent infection.

Glove Use Policy

Guidelines on when and how to properly use gloves in patient care.

Wound Healing Stages

Include inflammation, proliferation, and maturation stages.

Antimicrobial Agents

Substances that kill or inhibit the growth of microorganisms.

Environmental Cleaning

Regular cleaning to reduce microbial load and prevent infection.

Post-exposure Prophylaxis

Treatment to prevent infection after exposure to infectious agents.

Antibodies

Proteins produced by the immune system to neutralize pathogens.

Immunization

Vaccinations to enhance immunity against specific infections.

Flushing Protocols

Methods for cleaning and disinfecting surfaces to prevent contamination.

Patient Education

Informing patients about their conditions and ways to manage their health.

Oxygen Therapy Safety

Measures to ensure safe administration of oxygen to patients.

Nursing Outcomes

Goals established to measure the success of nursing interventions.

Biohazard Waste Disposal

Proper methods of disposing of potentially infectious materials.

Risk Assessment

Evaluating a patient’s potential risks for health complications.