Nursing Process, EBP, Communication, Documentation, and Patient Education - Vocabulary Flashcards

Vocabulary flashcards covering key terms from the Nursing Process, Evidence-Based Practice, documentation, health assessment, communication, and patient education topics as presented in the notes.

Evidence-Based Practice (EBP)

A systematic approach that integrates best available research evidence, clinical expertise, and patient preferences to guide safe, effective nursing care.

Nursing Process

A systematic, patient-centered framework of five steps used to plan and deliver care: Assessment, Diagnosis, Planning, Implementation, Evaluation.

ADPIE

Acronym for the five steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation.

Critical Thinking

Reflective thinking used to analyze information and solve problems in clinical practice.

Clinical Judgment

Nurse’s ability to make informed care decisions based on critical thinking and patient context.

Research

Systematic investigation to establish facts and inform practice; core to evidence-based care.

Standardized Care Protocols

Predefined, evidence-based procedures that reduce variability in practice and enhance safety.

Risk Reduction (EBP)

Interventions identified to prevent errors, complications, or adverse events in care delivery.

Decision Making (EBP)

Using research data, clinical expertise, and patient preferences to guide nursing decisions.

SMART Outcomes

Specific, Measurable, Attainable, Relevant, Time-bound outcomes used to describe patient goals.

Nursing Diagnosis

A clinical judgment about the patient’s response to health problems or potential problems that nurses address.

Problem-Focused Nursing Diagnosis

A diagnosis that identifies an actual problem the patient is currently experiencing, with etiology and signs/symptoms.

Risk Nursing Diagnosis

A diagnosis that identifies a potential problem a patient is at risk for due to factors or conditions.

Health Promotion Nursing Diagnosis

A diagnosis describing readiness to improve health or wellbeing.

Subjective Data

Information provided by the patient about feelings, perceptions, and health history.

Objective Data

Observable and measurable data obtained by the clinician during examination or tests.

Health Assessment

Systematic evaluation of health status, incorporating data from history and physical examination.

Health History

Subjective data about past and present health provided by the patient.

Inspection

Visual examination to assess size, shape, color, symmetry, and abnormalities.

Palpation

Tactile examination assessing texture, temperature, moisture, tenderness, and edema.

Auscultation

Listening to internal body sounds with a stethoscope (heart, lungs, bowel).

Percussion

Tapping to evaluate underlying structures’ density and borders.

Vital Signs

Core health measurements: temperature, pulse, respiration, blood pressure, and often SpO2.

Temperature

Measurement of body heat; normal ranges vary by site (oral, tympanic, rectal, axillary).

Pulse

Heart rate; number of beats per minute; normal range ~60–100 bpm.

Respiration

Breathing rate, depth, rhythm, and effort; normal ~12–20 breaths/min.

Blood Pressure

Force of blood against arterial walls; expressed as systolic/diastolic; influenced by many factors.

HIPAA Privacy Rule

Federal standard protecting patient health information (PHI) and governing privacy and disclosure.

PHI (Protected Health Information)

Identifiable health information that must be kept private under HIPAA.

Documentation

Recording patient data and care; should be accurate, timely, complete, objective, and compliant.

Electronic Health Record (EHR)

Digital version of a patient’s chart enabling bedside documentation and data sharing.

Focus Charting

Documentation focusing on data, problems, interventions, and outcomes for each patient issue.

SOAP Charting

Documentation format: Subjective, Objective, Assessment, Plan.

PIE Charting

Problem, Intervention, Evaluation; problem-oriented documentation.

Charting by Exception (CBE)

Documenting only deviations from defined standards or norms.

MARI/MAR (Medication Administration Record)

Record used to document medications administered to a patient.

SBAR

Structured handoff communication: Situation, Background, Assessment, Recommendation.

ISBAR

Identification, Situation, Background, Assessment, Recommendation; a handoff variant.

Incident/Variance Report

Documentation of an unusual event or error for quality improvement; not punitive.

Nurse Practice Act (NPA)

Legal statute defining the scope of nursing practice in a jurisdiction.

Scope of Practice

Legal boundaries of nursing practice as defined by NPA and institutional policy.

Bloom’s Domains

Learning domains: cognitive (knowledge), psychomotor (skills), affective (attitudes/values).

Readiness to Learn

Patient’s motivation, ability, and timing to engage in teaching.

Teach-Back

Strategy to confirm understanding by having patients repeat information in their own words.

Health Promotion vs Disease Prevention

Health promotion enhances overall wellbeing; disease prevention avoids specific illnesses.

Barriers to Teaching

Obstacles such as emotional factors, cognitive limits, language, literacy, and time constraints.

Lifespan Considerations

Age-related factors affecting health education for adults and older adults.

Therapeutic Communication

Professional, patient-centered communication that fosters trust and collaboration.

Social Communication

Casual communication not focused on patient care.

Nonverbal Communication

Body language, facial expressions, gestures; can reinforce or hinder messages.

Verbal Communication

Spoken or written language used to convey information.

Patient-Centered Care

Care that respects patient preferences, needs, values, and goals; partnership with patients.

Direct vs Indirect Interventions

Direct: hands-on patient care; Indirect: actions that support care without direct contact.

Health History vs Health Assessment

Health history collects past/present subjective data; health assessment evaluates current status using objective data.

Baseline Data

Initial measurements used for comparison over time.

Pulse Oximetry

Noninvasive measurement of oxygen saturation (SpO2) via a pulse oximeter.

Oxygen Saturation

Percentage of hemoglobin bound with oxygen.

Temperature Measurement Sites

Common sites: oral, rectal, axillary, tympanic, forehead.

Normal Ranges (General Adult Health)**

Common references: temperature ~37°C (varies by site), pulse 60–100 bpm, RR 12–20/min, BP roughly 90–120/60–80 mmHg.

Head-to-Toe Assessment

Comprehensive, systematic exam from head to toe to assess overall health.