Fundamentals of Nursing: Foundations, Care Delivery, Law, Documentation, and Infection Control

Comprehensive vocabulary flashcards covering medical asepsis, pressure injury stages, clinical documentation methods, nursing laws and ethics, healthcare delivery and economics, and the history and development of modern nursing.

Pathogens

Microorganisms capable of causing infection and disease in humans.

Normal Flora

Beneficial microorganisms that naturally reside in and on the human body without causing disease under ordinary conditions.

Coccus

A bacterium with a spherical or round cellular morphology.

Bacillus

A bacterium characterized by a rod-shaped physical structure.

Spirillum

A bacterium having a curved, corkscrew, or spiral-shaped morphology.

Staphylococci

Spherical bacteria arranged in irregular, grape-like clusters.

Streptococci

Spherical bacteria organized in linear chains.

Gram Stain

A laboratory staining procedure utilizing a dark purple dye to categorize bacteria into gram-positive or gram-negative groups.

Culture and Sensitivity

A laboratory diagnostic examination where the culture isolates and grows the specific pathogen, while the sensitivity test determines which antibiotic effectively treats it.

Spore

A dormant, protective bacterial structure capable of surviving for years without moisture, resisting heat and harsh chemicals, and reactivating when environmental conditions become favorable.

Vector

An organism (such as a tick, mite, or insect) that transmits infectious pathogens to humans via bites.

Viruses

Extremely small, obligate parasitic pathogens that require living host cells to reproduce and cause illness.

Protozoa

Single-celled microscopic parasitic animals that dwell in water or contaminated food, frequently causing intestinal illness such as dysentery and malaria.

Fungi

Primitive organisms of the plant kingdom that exist harmlessly in the external environment but induce disease upon entering broken skin or mucous membranes.

Ringworm (Tinea)

A contagious fungal infection caused by Microsporum or Epidermophyton, presenting as ring-shaped erythematous skin lesions.

Helminths

Parasitic worms, including pinworms and tapeworms, that colonize the human gastrointestinal tract after entering through the mouth.

Pinworms (Enterobius)

Small parasitic nematodes that infest the digestive tract and migrate to the perianal area.

Tapeworm (Taenia)

A segmented parasitic flatworm that infects the gastrointestinal system following ingestion.

Chain of Infection

A cyclical process detailing the spread of communicable diseases consisting of six continuous links: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

Health Care-Associated Infection (HAI)

An infection acquired by a patient while receiving treatment within any healthcare delivery setting.

Primary Infection

The initial localized or systemic illness caused by a single causative pathogen.

Secondary Infection

An infection produced by a second, different pathogen following an initial infection.

Systemic Infection

An infection that disseminates from an initial focal site into other body organs via the bloodstream.

Septicemia

A critical, severe clinical condition resulting from pathogens actively proliferating and multiplying within the circulatory bloodstream.

Primary Defenses Against Infection

The body's innate anatomical and physiological barriers that block pathogen invasion, consisting of intact skin, mucous membranes, and the gastrointestinal tract.

Secondary Defenses Against Infection

Cellular and physiological defense mechanisms provoked once pathogens enter the body, including the inflammatory response, elevated temperature (fever), and the complement cascade.

Tertiary Defenses Against Infection

Specific, acquired immune responses mediated by specialized lymphocytes, particularly T cells and B cells.

Standard Precautions

A foundational group of safety measures implemented during the care of all patients to prevent contact with blood, body fluids, secretions, excretions, and non-intact skin.

Transmission-Based Precautions

Specific infection control precautions implemented in addition to standard precautions for patients with diagnosed or suspected communicable diseases spread by contact, droplet, or airborne routes.

Airborne Precautions

Infection control measures for lightweight infectious particles that remain suspended in air currents (such as tuberculosis and measles), mandating a fit-tested N95 respirator and a negative-pressure isolation room.

Order of Donning Personal Protective Equipment

The standardized sequence for donning protective equipment: Gown first, followed by Mask, Goggles, and finally Gloves.

Order of Doffing Personal Protective Equipment

The standardized sequence for safely removing protective equipment: Gloves first, followed by Goggles (if worn), Gown, and finally Mask.

Medical Asepsis

Practices and clean techniques designed to reduce the overall count of microorganisms, inhibit their transmission, and eliminate reservoirs.

Surgical Asepsis

Sterile techniques and procedures utilized to eliminate all viable microorganisms before entering sterile body cavities or performing invasive procedures.

Contusion

A closed mechanical soft-tissue wound (bruise) where broken capillaries bleed into interstitial space under intact skin.

Abrasion

A superficial open wound produced by mechanical friction that scrapes away the outer layers of the epidermis.

Puncture Wound

An open wound produced by a sharp, pointed object that penetrates deeply into tissues leaving a small exterior opening.

Penetrating Wound

A puncture-style wound where the sharp causative object remains embedded or lodged inside the body tissues.

Laceration

An open, torn wound characterized by irregular, jagged tissue edges typically caused by sharp metal or glass.

Clean-Contaminated Wound

A surgically created wound that does not exhibit infection but enters a body tract naturally harboring normal flora, carrying an elevated risk of infection.

Purulent Drainage

Thick, opaque wound exudate composed of cellular debris, dead leukocytes, and bacteria, commonly referred to as pus.

Eschar

Hard, dry, leathery, black or dark brown dead necrotic tissue covering a full-thickness wound bed.

Pressure Injury

Localized tissue necrosis or damage caused by prolonged pressure and shearing forces between a bony prominence and an external surface.

Shearing

A mechanical force generated when skin remains stationary against a surface while underlying skeletal structures and tissues slide downward.

Stage 1 Pressure Injury

An area of intact skin displaying localized, non-blanchable erythema, often accompanied by differences in firmness, edema, or local temperature.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis, appearing as an open shallow ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister.

Stage 3 Pressure Injury

Full-thickness loss of skin in which adipose tissue is visible within a deep crater-like wound bed, without exposure of muscle, tendon, or bone.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with extensive tissue necrosis and direct exposure of muscle, tendon, ligament, cartilage, or bone.

Unstageable Pressure Injury

Full-thickness tissue loss in which the actual anatomical depth of the ulcer is completely obscured by slough or eschar.

Deep Tissue Injury

Persistent, non-blanchable localized area of intact skin exhibiting deep red, maroon, or purple discoloration due to underlying soft tissue injury.

Braden Scale

A clinical assessment scoring tool evaluating sensory perception, moisture, physical activity, mobility, nutritional intake, and friction/shear to predict pressure injury risk.

Charting

The formal recording of pertinent therapeutic, diagnostic, and clinical data within a patient's medical record.

Incident Report

A formal, objective internal agency form documenting an unusual occurrence, accident, or medication error, sent to Risk Management and omitted from the medical record.

Nursing Care Plan

A written clinical tool reflecting the nursing process that outlines patient-specific problems, expected outcomes, individualized interventions, and ongoing evaluations.

Electronic Health Record (EHR)

A digital lifetime compilation of an individual's health information that provides communication and improves safety across multidisciplinary clinical teams.

Charting by Exception (CBE)

A documentation method utilizing standardized flow sheets and checklists where only significant findings or deviations from defined clinical norms are charted.

SOAP / SOAPIER Charting

A structured progress note format organized by Subjective data, Objective data, Assessment, Plan, Intervention, Evaluation, and Revision.

PIE Charting

A documentation structure focused on Problem identification, Intervention delivery, and Evaluation of clinical response.

Focus (DAR) Charting

A client-centered charting style that organizes clinical entries into Data (assessment), Action (nursing implementation), and Response (patient outcome).

Narrative Charting

A traditional clinical recording system where client status, nursing actions, and events are documented chronologically in continuous paragraph form.

Kardex

A specialized reference card or file system used in nursing facilities to provide quick access to physician orders, current treatments, and resident care needs.

Medication Administration Record (MAR)

A specialized ledger tracking all ordered medications, precise dosages, scheduled times, and the exact administration status for a client over a month-long cycle.

OASIS Form

The Outcome and Assessment Information Set; a federally required comprehensive admission assessment completed by an RN for home healthcare patients.

Military Time

A 24-hour timekeeping format utilizing a four-digit numerical sequence to document care without a.m. or p.m. confusion.

Values

An individual's most deeply held personal beliefs and standards, commonly developed through family upbringing, religious tenets, and life experiences.

Ethics

A system of moral principles rooted in the Greek word ethos that establishes standards of right versus wrong conduct.

Ethical Dilemma

A complex clinical scenario requiring a choice between two conflicting moral alternatives where no clear, objectively correct solution exists.

Nurse Advocacy

The core nursing responsibility of prioritizing and standing up for the patient's best interests, rights, and autonomy against competing external demands.

Beneficence

The ethical duty to perform actions that promote good and actively advance the welfare and best interests of the patient.

Nonmaleficence

The ethical obligation of healthcare providers to do no harm, preventing unnecessary injury or suffering.

Autonomy

The ethical principle recognizing a competent patient's right to self-determination and independent choice without coercion.

Veracity

The ethical duty to communicate honestly and refrain from misleading or deceiving patients.

Fidelity

The ethical commitment to be faithful to promises, agreements, and professional care responsibilities.

Justice

The ethical principle requiring equal, fair, and impartial treatment of all patients without discrimination.

Whistle-Blowing

Reporting unsafe, fraudulent, or unethical medical practices to protect patient welfare despite personal career risks.

Do-Not-Resuscitate (DNR) Order

A formal clinical order dictating that cardiopulmonary resuscitation shall not be initiated if cardiac or pulmonary arrest occurs.

Nurse Practice Act (NPA)

State-specific legislation that defines the legal scope of practice and sets practice boundaries for nurses to protect the public.

State Board of Nursing

The regulatory state agency charged with licensing nurses, enforcing the Nurse Practice Act, and executing disciplinary proceedings.

HIPAA

The Health Insurance Portability and Accountability Act, a federal statute that establishes mandatory standards for safeguarding protected patient health information.

Negligence

A general tort describing the failure of an individual to exercise the reasonable degree of prudence and care that an ordinary person would provide under similar circumstances.

Malpractice

Professional negligence occurring when a licensed clinician fails to meet professional standards of care, directly causing patient injury.

False Imprisonment

The unlawful detention or unauthorized physical or chemical restriction of an individual's freedom of movement without consent.

Assault

An intentional act or spoken threat that creates a justifiable apprehension of harmful or offensive physical contact in another person.

Battery

The unauthorized, intentional physical touching or contact with a patient's person without consent.

Informed Consent

A patient's voluntary legal authorization for a medical procedure based on a complete understanding of its purpose, risks, and alternatives.

Advance Directives

Written legal documents, including living wills, specifying an individual's treatment preferences if they become incapacitated and unable to communicate.

Health Care Proxy

A durable medical power of attorney appointing an authorized agent to execute healthcare decisions for an incapacitated patient.

Medical Necessity

Healthcare interventions and treatments considered clinically appropriate, necessary, and reasonable by clinical standards.

Long-Term Acute Care Hospital (LTACH)

An inpatient facility providing intensive specialized interventions (such as extended mechanical ventilation) for patients with complex medical conditions, commonly spanning $20\text{ to }30\text{ days}$.

Skilled Nursing Facility (SNF)

An inpatient transitional healthcare facility providing skilled nursing and therapy services for a covered duration of up to a $100\text{-day}$ maximum.

Rehabilitation Facility

A specialized facility providing multidisciplinary physical, occupational, and speech therapy for patients able to tolerate at least $3\text{ hours}$ of daily active rehabilitation.

Assisted Living Facility

A residential setting offering relatively independent seniors assistance with daily activities, medication supervision, and meals in a community environment.

Hospice

A coordinated palliative care program designed to manage pain and offer holistic support for terminally ill patients whose life expectancy is $6\text{ months}$ or less.

Team Nursing

A nursing care delivery system where an RN team leader collaborates with other nurses and unlicensed assistive personnel to care for a designated group of patients.

Primary Care Nursing

A care delivery model where one designated nurse assumes round-the-clock clinical responsibility and care planning for an assigned patient throughout their stay.

Case Management

A collaborative nursing system in which a nurse coordinates care, facilitates transitions, and acts as an advocate to achieve clinical efficiency across health settings.

Client-Centered Care

A delivery approach empowering patients to direct their care while utilizing cross-trained personnel to decrease the total number of hospital caregivers.

Medicare

A federal government health insurance program for individuals aged $65$ and older, as well as qualified disabled individuals with permanent conditions like end-stage renal disease.

Diagnosis-Related Groups (DRGs)

A standardized prospective payment schedule classifying clinical diagnoses into fixed monetary reimbursement amounts paid to acute hospitals.

Medicaid

A joint federal and state assistance program providing medical coverage for qualifying low-income individuals, medically indigent patients, and certain disabled persons.