Unit 2 Key Terms

APIE note

A documentation format organized by Assessment, Planning, Intervention, and Evaluation.

Bar-code medication administration (BCMA)

An electronic safety system that uses barcode scanning to verify the right patient and right medication before administration.

Charting by exception (CBE)

A documentation system in which only abnormal findings or deviations from established standards are recorded in detail.

Confidentiality

The ethical and legal duty to protect patient information from unauthorized disclosure.

DAR note

A focus charting format consisting of Data, Action, and Response.

Electronic health record (EHR)

A comprehensive digital health record that can be shared across multiple health care settings.

Electronic medical record (EMR)

A digital version of the patient chart used primarily within one health care organization.

Handoff

The transfer of essential patient information, responsibility, and accountability from one caregiver to another.

Health care documentation

The accurate, timely, and complete recording of patient status, care provided, and responses to treatment.

Health Insurance Portability and Accountability Act (HIPAA)

Federal legislation that protects the privacy and security of patient health information.

Medical record

The legal and clinical record of a patient’s health history, care, treatment, and outcomes.

Medication administration record (MAR)

The part of the medical record used to document prescribed medications and their administration.

PIE note

A documentation format organized by Problem, Intervention, and Evaluation.

Privacy

The patient’s right to control personal information and physical access to self.

SBAR

A standardized communication framework for Situation, Background, Assessment, and Recommendation.

Sentinel event

An unexpected occurrence involving death, serious physical injury, or severe psychological injury, or the risk thereof.

SOAP note

A documentation format organized by Subjective data, Objective data, Assessment, and Plan.

SOAPIE note

SOAP format expanded to include Intervention and Evaluation.

SOAPIER note

SOAPIE format expanded to include Revision of the care plan.

Afebrile

Without fever.

Apical pulse

The pulse auscultated over the apex of the heart, typically at the fifth intercostal space at the left midclavicular line.

Apnea

Absence of breathing.

Arrhythmia

An abnormal heart rhythm. In many nursing texts, used interchangeably with dysrhythmia.

Auscultation

Listening to internal body sounds, especially heart, lung, and bowel sounds.

Blood pressure

The force exerted by circulating blood against the walls of the arteries.

Bradycardia

An abnormally slow heart rate, generally less than 60 beats/minute in adults.

Bradypnea

An abnormally slow respiratory rate.

Core temperature

The temperature of the deep tissues and internal organs of the body.

Cyanosis

Bluish discoloration caused by inadequate oxygenation.

Diastolic pressure

The arterial pressure during ventricular relaxation.

Dyspnea

Difficult or labored breathing.

Dysrhythmia

An abnormality in the rate, rhythm, or conduction of the heartbeat.

Eupnea

Normal, unlabored breathing.

Febrile

Having a fever.

Fever

An elevation in body temperature above normal, usually due to a regulated rise in the hypothalamic set point.

Frostbite

Tissue injury caused by freezing.

Heat exhaustion

A heat-related condition characterized by fluid and electrolyte loss, weakness, sweating, and elevated temperature without major neurologic dysfunction.

Heatstroke

A life-threatening heat emergency marked by extremely elevated temperature and central nervous system dysfunction.

Hypertension

Persistently elevated arterial blood pressure.

Hyperthermia

An elevated body temperature caused by failure of heat-regulating mechanisms, not by an increased hypothalamic set point.

Hyperventilation

Rapid or deep breathing in excess of metabolic need, often lowering carbon dioxide levels.

Hypoxemia

A decreased level of oxygen in the arterial blood.

Korotkoff sounds

The sounds heard during blood pressure measurement as the cuff pressure is released.

Orthopnea

Difficulty breathing when lying flat.

Orthostatic hypotension

A drop in blood pressure that occurs with position change, usually from lying or sitting to standing.

Oxygen saturation

The percentage of hemoglobin binding sites occupied by oxygen.

Palpation

Use of touch to assess characteristics such as pulse amplitude or skin temperature.

Peripheral pulse

A pulse palpated at an artery away from the apex of the heart, such as radial or pedal pulses.

Pulse

The palpable bounding of blood flow in an artery created by ventricular contraction.

Pulse deficit

The difference between apical and peripheral pulse rates.

Pulse oximetry

A noninvasive method of measuring arterial oxygen saturation.

Radial pulse

The peripheral pulse palpated at the radial artery on the thumb side of the wrist.

Respiration

The act of breathing, including inhalation and exhalation.

Systolic pressure

The maximum arterial pressure during ventricular contraction.

Tachycardia

An abnormally rapid heart rate, generally greater than 100 beats/minute in adults.

Tachypnea

An abnormally rapid respiratory rate.

Temperature

The balance between heat produced and heat lost by the body.

Vital signs (VS)

Core physiologic measurements that reflect essential body function, commonly temperature, pulse, respirations, blood pressure, oxygen saturation, and pain.

Airborne transmission

Spread of infectious agents by tiny particles that remain suspended in air and can be inhaled by others.

Antibodies

Immunoglobulin proteins produced by B lymphocytes in response to specific antigens.

Antigen

A substance recognized as foreign that stimulates an immune response.

Asepsis

The absence of pathogenic microorganisms.

Bacteria

Single-celled microorganisms that may be harmless, beneficial, or pathogenic.

Cellular immunity

Immune protection mediated primarily by T lymphocytes rather than antibodies.

Contact

Transmission of infectious organisms by direct touch or indirect contact with contaminated objects.

Disinfection

The elimination of many or all pathogenic microorganisms, except bacterial spores, on inanimate objects.

Droplet transmission

Spread of infection by large respiratory droplets that travel short distances and deposit on mucous membranes.

Fungi

Organisms such as yeasts and molds that can cause infection, especially in immunocompromised hosts.

Health care–associated infections (HAIs)

Infections acquired during the delivery of health care that were not present or incubating at admission.

Host (reservoir)

The person, animal, substance, or place in which an infectious agent normally lives and multiplies.

Humoral immunity

Antibody-mediated immunity produced by B lymphocytes.

Immune response

The body’s coordinated reaction to foreign substances or pathogens.

Immunization

The process of inducing immunity, usually by vaccination.

Infection

Invasion and multiplication of pathogenic microorganisms in the body resulting in tissue reaction.

Inflammatory response

A local and systemic protective reaction to tissue injury or infection characterized by vascular and cellular changes.

Medical asepsis

Clean technique used to reduce the number and spread of microorganisms.

Mode of transmission

The method by which an infectious agent is transferred from reservoir to host.

Normal flora

Microorganisms that normally reside in or on the body without causing disease under usual conditions.

Parasite

An organism that lives on or within another organism and derives nourishment at the host’s expense.

Pathogen

A microorganism capable of causing disease.

Personal protective equipment (PPE)

Specialized clothing or barriers such as gloves, gowns, masks, and eye protection used to reduce exposure to infectious material.

Portal of entry

The route through which a pathogen enters a susceptible host.

Portal of exit

The route by which a pathogen leaves its reservoir.

Replication

The process by which microorganisms reproduce.

Sterilization

The complete destruction of all microorganisms, including spores.

Surgical asepsis

Sterile technique used to eliminate all microorganisms and spores from an area or object.

Susceptible host

A person at risk for infection because defenses are inadequate against a particular pathogen.

Vectors

Living carriers, such as mosquitoes or ticks, that transmit infectious organisms.

Viruses

Submicroscopic infectious agents that require living host cells to reproduce.

Activities of daily living (ADLs)

Basic self-care activities required for independent functioning, such as bathing, dressing, toileting, feeding, and grooming.

Axilla

The armpit.

Dandruff

Flaking of the scalp, usually associated with seborrheic irritation or dry skin.

Dentures

Artificial replacements for missing teeth and surrounding oral structures.

Epithelial tissue

Protective tissue that covers body surfaces, lines cavities, and forms glands.

Excoriation

Loss of superficial skin resulting from friction, scratching, or irritation.

Halitosis

Bad breath.

Hygiene

Practices that maintain cleanliness and promote health.

Integumentary system

The body system composed of skin, hair, nails, and associated glands that protects the body and helps regulate temperature.

Mastication

Chewing.

Mucous membranes

Moist epithelial linings of body cavities and passages that open to the exterior.