Nursing Process, Communication, Vital Signs, and Documentation Review

Vocabulary practice flashcards covering fundamental nursing concepts including the Nursing Process (ADPIE), Communication, Physical Assessment, Vital Signs measurement, and Documentation methods.

Nursing Process

A systematic problem-solving method that serves as the organizational framework for nursing practice to identify health problems and plan individual patient care.

ADPIE

An acronym for the five sequential components of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Primary Source

The client or patient, who serves as the main source of health data during nursing assessment.

Secondary Sources

All sources of patient information other than the client, including family, physician History and Physical, laboratory and diagnostic results, and other health personnel.

Nursing Diagnosis

A clinical judgment regarding an actual or potential health problem that can be prevented, reduced, resolved, or enhanced through independent nursing measures, distinguishing it from a medical diagnosis.

NANDA-I

North American Nursing Diagnosis Association International; the governing body that publishes updated evidence-based nursing diagnoses every $2$ years in Taxonomy II.

Goal (Nursing Planning)

A written statement describing measurable, observable behavior that the client should demonstrate following nursing interventions, formatted to begin with 'The patient/client will…'.

SMART Goals

An acronym defining essential goal-setting criteria: Specific, Measurable, Achievable, Realistic, and Timely.

Short-Term Goal

A outcome goal achievable within hours, days, or weeks, with a general timeframe within $6$\text{ months}.

Long-Term Goal

An outcome goal addressing the long-lasting impact of an illness or disease, with a timeframe generally of $6$\text{ months} or more, or open-ended.

Signs

Objective data collected through the nurse's four senses (vision, hearing, olfaction, and touch) that can be directly observed and measured.

Symptoms

Subjective evidence of illness or injury reported verbally by the patient that cannot be directly observed or measured, such as pain, dizziness, or nausea.

Comprehensive Assessment

An in-depth physical assessment of the whole person, covering physical, mental, emotional, cultural, and spiritual aspects of health, performed by the Registered Nurse upon admission.

Focused Assessment

An examination and interview targeted toward a specific body system or clinical health issue, frequently conducted by LPNs to collect patient data and assist care.

Initial Head-to-Toe Shift Assessment

A quick overall examination of a patient's physical condition performed at the start of a nursing shift to establish a clinical baseline.

Inspection

The visual examination of a client's body to observe skin conditions and normal appearance of body structures.

Auscultation

The technique of listening to body organs with a stethoscope to identify normal or abnormal sounds in the lungs, heart, or bowel.

Palpation

The assessment technique of using hands or fingertips to touch torso and limbs for pulses, abnormal lumps, temperature, moisture, and vibrations.

Percussion

The assessment technique of using light tapping movements against the body to detect structural or fluid abnormalities of internal organs.

Core Temperature

The temperature of deeper body tissues and structures, measured most accurately via the rectal route, which is about $1^\circ\text{F}$ higher than oral temperature.

Pyrexia

Fever or elevated body temperature, commonly referring to readings above $105^\circ\text{F}$ ($40.5^\circ\text{C}$).

Point of Maximum Impulse (PMI)

The specific anatomical chest location where the apical pulse is best auscultated, located at the left $5\text{th}$ intercostal space along the midclavicular line.

Pulse Deficit

The numerical discrepancy detected when the apical pulse rate and a peripheral pulse rate are measured simultaneously.

Tachypnea

A respiratory rate above $20\text{ breaths/min}$.

Bradypnea

A abnormally slow resting respiratory rate below $12\text{ breaths/min}$.

Apnea

The temporary or complete cessation of breathing, which can cause tissue damage or death if prolonged past $4$\text{ to }$6\text{ minutes}$.

Dyspnea

Labored, difficult, or painful breathing.

Orthopnea

Inability to breathe comfortably unless maintaining an upright sitting or standing position.

Cheyne-Stokes Respiration

A breathing pattern with alternating periods of deep, rapid breathing and periods of apnea, often indicating critical clinical deterioration or approaching death.

Kussmaul's Respiration

An abnormal respiratory pattern characterized by increased rate and depth with deep, forceful, blowing or grunting exhalations.

Biot's Respiration

An irregular breathing pattern featuring abnormally fast and deep breaths interspersed with abrupt periods of apnea.

Systolic Blood Pressure

The maximum blood pressure exerted against arterial walls during the active ventricular contraction phase of the heart.

Diastolic Blood Pressure

The minimal blood pressure within arterial walls when the heart's ventricles are resting between beats.

Pulse Pressure

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

Korotkoff Sounds

A arterial blood flow sound heard via stethoscope placed over an artery (such as the brachial artery) during cuff deflation.

Hypertension

Elevated blood pressure defined as a sustained systolic reading above $130\text{ mmHg}$ or diastolic reading above $80\text{ mmHg}$.

Hypotension

Abnormally low blood pressure occurring when blood pressure drops $20\text{ to }30\text{ mmHg}$ below baseline or falls below $100/60\text{ mmHg}$.

Capillary Nail Refill Test

An assessment of tissue perfusion and hydration performed by pressing a nail bed until blanched; normal capillary refill time is $1\text{ to }2\text{ seconds}$, while time greater than $2\text{ seconds}$ indicates poor perfusion.

Wong-Baker FACES Pain Rating Scale

A visual pain rating tool utilizing six standardized facial expressions scaled from $0$ ('No Hurt') to $10$ ('Hurts Worst') for patient self-reporting.

Military Time

A 24-hour timekeeping format beginning at midnight ($0000$ or $2400$) used in health care documentation to eliminate duplication and AM/PM confusion.

SOAP Charting

A progress note documentation format organized by Subjective data ($S$), Objective data ($O$), Analysis ($A$), and Plan of care ($P$).

Charting by Exception

A documentation method in which nurses chart only abnormal assessment findings or care deviations that vary from established norms.

Narrative Charting

A traditional charting method in which clinical information and nursing care are recorded in detailed chronological prose entries.

SBAR Technique

A standardized clinical communication framework structuring information into Situation ($S$), Background ($B$), Assessment ($A$), and Recommendation ($R$) to improve patient handoffs.

Kardex

A quick-reference paper system kept centrally at the nursing station containing concise, current medical and care instructions for each patient.

Feedback

The receiver's reply to the sender in the communication process, verifying that the message was received and decoded correctly.

Sphygmomanometer

A diagnostic instrument consisting of an inflatable cuff, pressure gauge, inflation bulb, and valve used to measure arterial blood pressure.