Exam 1 - All Flashcards

Nurse who has advanced degrees and certification (e.g., nurse practitioner)

Professional nursing organization concerned with all aspects of professional nursing provides standards and leadership for the profession comprised of individual state nursing associations and also has nursing specialty bodies representing all nursing practice areas

Registered nurse who holds a master’s degree in a nursing specialty and has advanced clinical experience

• According to Lewin
• 1. Recognition of the area where change is needed
• 2. Analysis of a situation to determine what forces exist to maintain the situation and what forces are working to change it
• 3. Identification of methods by which change can occur
• 4. Recognition of the influence of group mores or customs on change
• 5. Identification of the methods that the reference group uses to bring about change
• 6. The actual process of change

• unfreezing, movement, and refreezing
• Unfreezing is the recognition of the need for change and the dissolution of previously held patterns of behavior. Movement is the shift of behavior toward a new and more healthful pattern. Movement marks the initiation of change. Refreezing is the long-term solidification of the new pattern of behavior.

Formal explanation that links concepts and emphasizes relationships among them

Context in which a person lives; includes social and inanimate characteristics

A framework for collecting and organizing nursing assessment data to ascertain the patient’s strengths and any actual or potential dysfunctional patterns

A systems framework that assumes all systems must be goal directed; a system is more than the sum of its parts; a system is ever-changing and any change in one part affects the whole; boundaries are implicit and in human systems are open and dynamic

• (1) State of well-being and optimal functioning;
• (2) Interactive process between the person and the internal and external environment

Any physiologic or psychological factors necessary for a healthy existence

Person licensed by a state after completing a state-approved nursing program to provide technical nursing care under the direct supervision of a registered nurse

Theory that states that all humans are born with instinctive needs, grouped into five categories, and arranged in order of importance from those essential to physical survival to those necessary to develop a person’s fullest potential

Part of Maslow's hierarchy of human needs - bottom of pyramid. Need for air, nutrition, water, elimination, rest, and sleep, and thermoregulation. Sex is unnecessary for individual survival, but it is necessary for the survival of humankind.

Part of Maslow's hierarchy of human needs - second from bottom of pyramid. Need for shelter and freedom from harm and danger.

Part of Maslow's hierarchy of human needs - third from bottom of pyramid. Need for affection, feelings of belongingness, and meaningful relations with others.

Part of Maslow's hierarchy of human needs - fourth from bottom of pyramid (second from top). Need to be well thought of by oneself as well as by others.

Part of Maslow's hierarchy of human needs - top of pyramind (fifth from bottom). Need to be self-fulfilled, learn, create, understand, and experience one's potential.

Nurse who supervises the organization of nursing care to ensure overall safety and quality

Nurse who specializes and is certified in the administration of anesthesia

Nurse responsible for nursing and healthcare education in various settings

Nurse with advanced education and certification in the care of women during pregnancy and childbirth

State guideline that governs the practice of professional nursing

Nurse with advanced education and certification who may practice independently in various settings

Nurse responsible for continued development of nursing knowledge and improvement of practice through research

Profession that involves diagnosis and treatment of human responses to actual or potential health problems

Explanation or description of nursing issues that defines and predicts nursing practice

Human being; recipient of nursing care

Nurse possessing the baccalaureate degree in nursing

Process of developing one’s maximum potential and managing one’s life confidently

Process in which a person is familiarized with the ways of a specific culture or group

A beginning nursing student or any nurse entering a situation in which he or she has had no previous experience. Behavior is governed by established rules and is limited and inflexible. The novice nurse moves from relying on abstract principles to using concrete experiences.

The advanced beginner can demonstrate marginally acceptable performance. He or she has had enough experience in actual situations to identify meaningful aspects or global characteristics that can be identified only through prior experience. Advanced beginner is identified as being the first 5 years after graduation from nursing school and is described as seeing situations in parts to seeing them more conceptually, or as a whole.

Competence is reflected by the nurse who has been on the same job for 2 or 3 years and who consciously and deliberately plans nursing care in terms of long-range goals. Competency occurs 5 to 10 years after graduation, and the nurse is no longer outside the situation observing but is directly involved.

The proficient nurse perceives situations as a whole rather than in terms of aspects and manages nursing care rather than performing tasks.

The expert nurse no longer relies on rules or guidelines to connect understanding of a situation to an appropriate action. The expert nurse, with an enormous background of experience, has an intuitive grasp of the situation and zeroes in on the problem. The expert nurse has an enormous background of experience, intuitive grasp of each situation, and accurately targets the problem without unnecessary consideration of a large range of alternative diagnoses and solutions.

The RN collects comprehensive data pertinent to the patient’s health or situation.

The RN analyzes the assessment data to determine the diagnoses or issues.

The RN identifies expected outcomes for a plan individualized to the patient or the situation.

The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes.

The RN implements the identified plan. This includes coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.

The RN evaluates progress toward attainment of outcomes.

The RN practices using ethical principles.

The RN practices in a manner that is congruent with cultural diversity and inclusion principles.

The RN communicates effectively in all areas of practice.

The RN collaborates with the patient and key stakeholders.

The RN demonstrates leadership in the practice setting and the profession.

The RN attains knowledge and competency that reflects current nursing practice and promotes futuristic thinking.

The RN integrates evidence and research findings into practice.

The RN contributes to quality nursing practice.

The RN evaluates one’s own and others’ nursing practice.

The RN utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible.

The RN practices in an environmentally safe and health manner.

A combination of patient care elements that can be consistently implemented to reduce harm

CMS - A federal organization that pays for healthcare for low-income and elderly people and tracks healthcare outcomes

A report filed that documents an accident or injury occurring in the hospital

An organization that focuses on safety of patients and that has developed a number of bundles of care to achieve that goal

A professional organization that has identified six aims of 21st century healthcare: that all healthcare should be safe, effective, patient-centered, timely, efficient, and equitable

Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.

Evidence-based practice - Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.

Quality improvement - Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.

Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

that all healthcare should be safe, effective, patient-centered, timely, efficient, and equitable

An approach to error evaluation that examines the nature of the error to assist in determining the appropriate response to the individual who made the error

The excellence or superiority of something; often viewed on a continuum, from poor quality to high quality

A project designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses

RCA - A process used to determine the underlying cause of an event. Asking why 5 times.

The avoidance or prevention of adverse outcomes for patients

The study of safety knowledge and technology to prevent harm to patients

Safety error in which hospitals are required to report serious safety events to regulatory agencies and state health agencies

Medications with similar names may lead to administration errors. The Institute for Safe Medication Practices (ISMP) has advocated a system of using capitalized letters within a drug name to differentiate drugs with similar names.

• Care bundle: central line–associated bloodstream infection. 5 elements:
• -Hand hygiene
• -Maximal barrier precautions during insertion of the line (sterile gown and gloves, cap, face shield, sterile drape)
• -Preparation of skin at insertion site with chlorhexidine
• -Optimal catheter site selection, avoiding the femoral vein site in adults
• -Daily review of line necessity with prompt removal when no longer needed

VBP - CMS adjusts hospital reimbursement based on adherence to guidelines for processes and outcomes of care and patient satisfaction.

Latent errors are those due to systems issues. The effects of latent errors may be apparent immediately and may certainly cause significant harm to patients.

Physician- or nurse-caused death that deliberately hastens a person’s death and may be considered murder in many states

Written document (e.g., living will) that states in advance a patient’s desires about the types of healthcare he or she wishes to receive should the patient become unable to decide

Threat of touching a person without his or her consent

Providing the patient with a means to end life, but not the direct action that results in death

A person’s dispositions toward an object or situation; can be a mental or emotional mind-set and positive or negative

Degree of discretion and independence a practitioner has

Unlawful touching of a person’s body without his or her consent

Observable actions

Ideas that a person accepts as true

Doing or promoting good, the basis for all healthcare

Irreversible cessation of heart and lung functions or an irreversible loss of all functions of the entire brain

Mental or physical ability to make healthcare decisions

The body of law that deals with relationships between private individuals

Document that requires the signatures of the primary physician or nurse practitioner and the patient or legal surrogate and allows emergency medical personnel, if called, to provide care and support to patient and family without resuscitation

Practice of keeping patient information private

Violation of the law punishable by the state. Results in prison term, fine, or short jail sentence to punish offender.

A type of public law that deals with the public’s safety and welfare

Orders not to provide resuscitation in the event of cardiopulmonary arrest

Advance directive that allows a person to designate another to make decisions if the patient becomes incapacitated and cannot make independent decisions

Professional standards of behavior related to right and wrong

Premeditated killing (first-degree murder) - impulsive or unintentional killing (second-degree murder; manslaughter, rape, arson, treason, kidnapping, burglary, bribery, child abuse, drug trafficking, fraud, and terrorism.

Being faithful to one’s commitments and promises

• Assault and battery
• Defamation of character
• Fraud
• Invasion of privacy
• False imprisonment

• Negligence
• Malpractice

Principle of fairness basis of the obligation to treat all patients equally and fairly

Standards of human conduct established and enforced by the authority of an organized society through its government

Responsibility for one’s actions an obligation one is bound to perform

False communication by means of print that results in injury to a person’s reputation

Written evidence of a patient’s preferences regarding treatment options

Professional misconduct, causing harm or injury to a person from lack of experience, skill, knowledge, or judgment

• -A duty to the plaintiff
• -A failure to meet the standard of care, or a breach of duty, which may be an act of omission
• -Causation (i.e., that the breach of duty produced the injury in a natural and continuous sequence)
• -Damages, which require a physical, emotional, financial, or other injury to the patient

The set of beliefs about the standards of right and wrong that help a person determine the correct or permissible action in a given situation

The ability to surmount fear and act to protect patient’s rights and values

An offense punishable by imprisonment of less than 1 year or a fine of less than $1,000. Does not amount to a felony.

Failure to do something that a reasonably prudent person would do, or doing something that a reasonably prudent person would not do

Order not to provide resuscitation in the event of a cardiopulmonary arrest

Principle of avoidance of doing harm

Beliefs a person considers highly important and are learned through interactions with social systems

Patient confidentiality

Values held by a disciplinary group deemed as having generalizable standards of conduct to be upheld in all situations

Advance directive that allows a person to designate another to make decisions if the patient becomes incapacitated and cannot make decisions independently

“The thing speaks for itself ” invoked when it is impossible to prove who was at fault when a patient’s injury results from negligence

“Let the master answer”; doctrine in which a facility is held liable for an employee’s negligence

Act of reviving after apparent death or unconsciousness

False communication by spoken word that results in injury to a person’s reputation

Comprise the expected level of performance or practice as established by guidelines, authority, or custom

Person identified to act on a patient’s behalf when the patient is an infant, young child, mentally handicapped or incapacitated, or in a

Infrequently used method of pain management, not considered euthanasia, provided in response to a dying person’s persistent and unremitting pain and suffering; it provides analgesia that produces light sedation even though this is likely to hasten death somewhat secondary to resulting immobility

Wrong committed against a person or property; subject to action in a civil court to assess compensation for plaintiff

Personal standards for decision making

Enduring set of personal principles and rules

Principle of telling the truth, essential to the integrity of the patient-provider relationship

Unquestioned framework or predominant set of assumptions through which people view life

Hope, Phase I - Security

Will, Phase I - Survival, Wonder

Purpose, Phase I - Awe

Competence, Phase II - Belonging, Work

Loyalty, Phase II - Self-competence, Self-worth

Love, Phase III - Independence, Service/vocation

Care, Phase III - Creation, Being self

Wisdom, Phase IV - Harmony, Interdependence, Intimacy, Esthetics

self determination, independent choice

to do or promote good – the client’s best interest, promote good as defined by the client

information shared in the course of treatment is not shared with others

fulfillment of one's duties and obligations and strict adherence to vows or promises

principle of fairness – treat all clients equally and fairly - equal share of available resources

to do no harm, to remove from harm to prevent harm

truthfulness, honesty

• -having the client tell them their name while looking at their wrist band
• -having the client tell them their birth date while looking at their wrist band
• -scanning their medical record number on their wrist band

• -A duty to the plaintiff
• -A failure to meet the standard of care, or a breach of duty, which may be an act of omission
• -Causation (i.e., that the breach of duty produced the injury in a natural and continuous sequence)
• -Damages, which require a physical, emotional, financial, or other injury to the patient

• -Assess the skills of the RN, LPN/LVN or UAP
• -Assess the client
• -Determine if a prudent nurse would delegate this intervention

Nursing Knowledge

interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes

identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patients’ preferences, experience and values to make practice decisions

• Informatics and Technology
• use information and technology to communicate, manage knowledge, mitigate error, and support decision making

will influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals

provide holistic care that recognizes an individual’s preferences, values, and needs and respects the patient or designee as a full partner in providing compassionate, coordinated, age and culturally appropriate, safe and effective care

demonstrate accountability for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principles

uses data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of health care systems

minimize risk of harm to patients and providers through both system effectiveness and individual performance

demonstrate an awareness of and responsiveness to the larger context of the health care system, and will demonstrate the ability to effectively call on microsystem resources to provide care that is of optimal quality and value.

function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development

Agent that stops or slows the growth of microorganisms on living tissue, commonly used for handwashing, skin preparation, and wound packing or irrigation

Absence of disease-producing microorganisms

Able to kill bacteria

Able to inhibit the growth of bacteria

Person from whom a microorganism can be cultured but who shows no sign of a disease

Chemical used to kill microorganisms on lifeless objects

(ESBLs) Enzymes that give bacteria immunity to both penicillin and cephalosporin antibiotics

Handwashing with soap and water or cleansing the hands with a water-less alcohol-based cleanser to prevent the spread of infection

(HAI) A term that encompasses infections contracted in all healthcare settings and is now used in place of the older term, nosocomial infection, which refers only to hospital-acquired infection

• Process resulting from infection that produces manifestations such as fever, leukocytosis, inflammation, or tissue damage
• Infectious disease refers to pathologic events that result from the invasion and multiplication of microorganisms in a host.

Techniques used to prevent or to limit the spread of infection

Measures taken to control and to reduce the number of pathogens present; also known as “clean technique”; measures include handwashing, gloving, gowning, and disinfecting to help contain microbial growth

Organisms that have developed resistance to multiple antibiotics

• Infection acquired during receipt of healthcare
• Nosocomial infections are those that occur in the setting of the hospital

Infections that do not result in disease in individuals with properly functioning immune systems

An organism’s ability to harm and to cause disease

Microorganisms that can harm humans

(PPE) Techniques or equipment that prevents the transfer of pathogens from one person to another; also referred to as “barriers”

Organisms that cause a rapidly progressing neurodegenerative disease affecting both animals and humans that is untreatable and always fatal

• Poisoning of body tissues; usually refers to bloodborne organisms or their toxic products
• Sepsis is an infection that manifests with systemic or widespread microbial destruction of tissues, often accompanied by high fever or hypotension.

Organism’s attraction to a specific host, which may include humans

The latest CDC isolation system that combines the major features of Universal Precautions (blood-borne transmissions) and Body Substance Isolation (moist body substances transmission), thus protecting against blood and body-fluid transmission of potentially infective agents

(1) Destruction of all bacteria, spores, fungi, and viruses on an item, accomplished by heat, chemicals, or gas; (2) Rendered unable to reproduce biologically

Refers to “sterile technique” in which an object is free of all microorganisms to prevent the introduction or spread of pathogens from the environment into the patient; employed when a body cavity is entered with an object that may damage the mucous membranes, when surgical procedures are performed, and when the patient’s immune system is already compromised

Vigor with which an organism can grow and multiply

• Overprescription of antibiotics
• Use of inappropriate antibiotics for the infecting organism
• Incomplete use of antibiotic prescriptions as symptoms subside
• Harboring and spreading of resistant organisms by carriers who remain symptom free, usually unaware that they have been infected
• Increased use of antibiotics in farming, thus contaminating milk and meat

• bacteria
• fungi
• virus
• parasites
• prions

• human beings
• animals
• inanimate objects

• sputum
• emesis
• stool
• blood

• Immunosuppressed elderly
• chronically ill
• trauma
• surgery

• mucous membranes
• nonintact skin
• GI tract
• GU tract
• respiratory tract

• contact
• vehicle
• droplet transmission
• airborne
• vectorborne

• Direct or indirect contact
• Direct - body surface to body surface
• Indirect - susceptible host comes in contact with contaiminated object

• contaiminated items that transmit pathogens
• e.g. food can carry Salmonella, water can carry Legionella, blood can carry hepatitis and HIV

Mucous membranes of nose, mouth, or conjuntiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Droplets do not remain suspended in the air for very long and seldom travel more than 3 feet. This is not the same as airborne transmission.

Fine particles are suspended in the air for a long time or when dust particles contain pathogens. Air currents widely disperse organisms, can be inhaled or deposited on the skin of a susceptible host. Patient must be in rooms with special air handling and ventilation systems.

• biologic or mechanical
• Biologic are living creatures carrying pathogens, e.g. rats, insects, birds. Most concerning in tropical areas; mosquitoes carrying malaria
• Mechanical vectors are inanimate objects contaiminated with infected body fluids, e.g. central line catheters, ventilators, contaiminated needles, syringes. MRSA, hepatitis B, HIV are commonly spread in this manner.

• hospitals, outpatient clinics, extended care facilities, the home, and schools - threat to those with decreased resistance.
• Sources include: air; other patients; families and visitors; and contaminated equipment, food, and personnel.
• Pneumonia and influenza is commonly spread in these facilities.

Drugs such as steroids, immunosuppressive agents, and cancer therapy, as well as prolonged use of antibiotics, predispose patients to infection. Equipment such as IV catheters, urinary catheters, feeding tubes, and ventilators provide routes for bacterial and fungal invasion. Inadequate dressing techniques for wounds can provide media for bacterial growth.

• Changes in the physical or psychological status of a patient can affect his or her resistance to infection. Any break in the integrity of the skin or mucous membranes increases the chance of infection.
• Stress, fatigue, poor nutrition, poor hygiene, and chronic illness also can decrease the patient’s ability to ward off infection by impairing normal defenses.
• The elderly are extremely susceptible to infection because of age-related changes to major body systems.
• Immunocompromised patients are the most susceptible to infection because they are unable to invoke the immune response necessary to fight off infection-causing pathogens.

Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome

• Infectious waste:
• Blood and blood products
• Pathology laboratory specimens
• Laboratory cultures
• Body parts from surgery
• Contaminated equipment (e.g., dialysis materials, suction receptacles)
• Injurious Waste:
• Needles
• Scalpel blades
• Lancets
• Broken glass
• Pipettes
• Aerosol cans
• Hazardous Waste:
• Radioactive materials
• Chemotherapy solutions
• Caustic chemicals

• C. difficile
• Norovirus
• wash hands after any contact with a patient with diarrhea

• Precautions:
• Private AIIR with adequate filtration; mask; mask worn by the patient during transport out of room
• Indications:
• Transmission via airborne route (small-particle droplets); tuberculosis, measles, varicella

• Precautions:
• Private room or cohabitation with the patient infected with same organism; mask required when working within 3 feet of the patient; mask worn by the patient during transport
• Indications:
• Transmission of large droplets through sneezing, coughing, or talking; Haemophilus influenzae, multidrug-resistant strains, Neisseria meningitidis, diphtheria, rubella, Mycoplasma pneumoniae

• Precautions:
• Private room or cohabitation with the patient infected with same organism; gloves at all times (don before entering room and remove before leaving) with change after exposure to organism; handwashing immediately after removal of gloves; gown and protective barriers when direct contact with organism occurs; daily cleaning of bedside equipment and patient care items; exclusive use of items such as stethoscope and sphygmomanometer for infected patient with terminal disinfection when precautions are no longer necessary
• Indications:
• Serious infections easily transmitted through direct contact; any multidrug-resistant strains, C. difficile, Shigella, impetigo, and others

Use of knowledge, critical thinking, and past performance to solve problems

Use of critical thinking to question why the patient has an abnormal finding

Ability to understand rights and responsibilities

Purposeful process that is disciplined, active, multidimensional, reasonable, rational, and reflective to arrive at insight and draw conclusions

The process of gathering and clustering data to draw inferences and propose diagnoses

Skills used to make nursing diagnoses

A life-sized mannequin with a sophisticated computer interface, which presents clinical scenarios that evolve based on decisions a user makes

How students learn best

Knowledge, experience, critical thinking, and clinical reasoning

Systematic approach to providing nursing care using assessment, diagnosis, outcome identification, planning, implementation, and evaluation

The patient

Identifying the main emotional themes contained in a communication and directing them back to the patient for the purpose of verifying and checking feelings that are being heard

Family, significant others, other healthcare professionals, health records, and literature review

assessment, (nursing) diagnosis, planning, implementation, and evaluation

First phase of the nursing process in which data are gathered to identify actual or potential health problems

Technique of listening to body sounds with a stethoscope

Practice of keeping patient information private

Pieces of data, subjective or objective, about a patient

Systematic visual examination of the patient

• Communication technique in which the nurse questions the patient in a goal-directed conversation
• Interaction and communication process for gathering data by questioning and information exchange

Observable, measurable information that can be validated or verified

Art of noticing patient cues

Use of the sense of touch to ascertain the size, shape, and configuration of underlying body structures

Examination by tapping the body surface with the fingertips and evaluating the sounds obtained

Use of the techniques of inspection, palpation, percussion, and auscultation to obtain information about the structure and function of body parts

Symptoms or covert cues that include the patient’s feelings and statements about his or her health problems

Reexamining information to check its accuracy

• Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction
• Baseline for reference and future comparison
• Within the specified time frame after admission to a hospital, skilled nursing facility, ambulatory healthcare center, or home healthcare setting

• Status determination of a specific problem identified during previous assessment
• Ongoing process; integrated with nursing care; a few minutes to a few hours between assessments

• Comparison of patient’s current status to baseline obtained previously; detection of changes in all functional areas after an extended period of time has passed
• Several months (3, 6, or 9 mo or more) between assessments

• Identification of life-threatening situation
• Any time a physiologic, psychological, or emotional crisis occurs

The patient is the primary source of data, and the information collected from the patient is considered to be the most reliable, unless circumstances such as altered level of consciousness, severe pain, impending surgery, acute illness, or age make data collection impossible. The patient is deemed unreliable if he or she is confused or suffering from physical or mental conditions that alter thinking, judgment, or memory. In these situations, secondary sources help provide the necessary assessment information.

• Secondary sources provide data that supplement, clarify, and validate information obtained from the patient.
• Family members or significant others supplement and verify information obtained from the patient, often providing information that the patient forgets to mention or is unwilling to reveal. They may be the only source of data for children or for confused, unresponsive, or severely ill patients. Data provided by family members and significant others include a description of how the patient reacts to illness, the patient’s perceptions of changes in health status, the patient’s ability to cope with life stressors, and information about the patient’s home situation.
• Usually, the patient’s permission is obtained before information is sought from family members or significant others. All people involved must understand the confidential nature of the information they provide. The patient’s permission must also be obtained to divulge any information (e.g., diagnosis of cancer, positive HIV status, pregnancy) to family members or significant others.

An existing human response to a health problem the nurse identifies that is amenable to nursing intervention

Patient data combined into meaningful patterns

Problems based on medical diagnoses, medically ordered treatments, or other related problems that require interdependent standards and activities to be addressed

Identified disease or pathologic process; treatment focuses on correcting or preventing specific pathology of specific organs or body systems

Actual, potential, or possible health problem identified by the nurse that is amenable to nursing intervention

Health problem amenable to nursing intervention that requires additional data collection and validation before it can be confirmed or deleted as a nursing diagnosis

Selecting a diagnosis before analyzing pertinent information

State of being at risk for the development of a health problem amenable to nursing intervention

Classification system to organize information

Reexamining information to check its accuracy

A graphical tool for organizing and representing knowledge

Judgment of the effectiveness of nursing care in achieving patient goals

Aim or expected end to which the nurse and patient work together

Any treatment the nurse performs to enhance patient outcomes based on clinical judgment and knowledge

Any treatment the nurse performs to enhance patient outcomes based on clinical judgment and knowledge

System of organizing desired patient outcomes according to categories, classes, labels, outcome indicators, and measurement activities for outcomes

A measurable statement of expectations

Specific, measurable, realistic statement of goal attainment

Formulation of goals and measurable outcomes that provides the basis for evaluation

Management function of deciding what to do, when, where, how, by whom, and with what resources

Nursing problem that takes on a position of prominence

Description of the parameter for achieving a goal

Reason for a nursing intervention that is supported by clinical research

Deviation that alters an expected outcome or date of discharge

• Transferring to a competent person the authority to perform a selected nursing task in a selected situation
• The transfer of responsibility for the performance of a task to another staff while retaining accountability for the outcome. A licensed RN will delegate tasks to unlicensed assistive personnel (UAP).

Judgment of the effectiveness of nursing care in achieving patient goals

Action phase of the nursing process in which nursing care is provided

System of organizing nursing interventions in a three-level taxonomy consisting of domains, classes, and interventions and developed by a research team at the University of Iowa College of Nursing

Any review completed by a nurse of a patient’s care or records to evaluate whether established standards were met

Evaluation and judgment of performance by other nurses

Mechanisms for healthcare organizations to assess and improve care

Comprise the expected level of performance or practice as established by guidelines, authority, or custom

• Teach/educate.
• Relate knowledge to activities of daily living (ADLs).
• Provide feedback.
• Create strategies for patients with dysfunctional communication.
• Delegate to UAP.
• Supervise nursing team.
• Supervise patient in performance.
• Supervise family in performance.
• Alter the environment as needed.

• Coordinate activities.
• Provide caregiving.
• Use therapeutic communication.
• Provide a personal presence.
• Set limits.
• Provide opportunity to examine values and attitudes.
• Explore and legitimize feelings.
• Provide spiritual support.
• Use humor.
• Provide individual therapy.
• Provide group therapy.
• Become patient’s advocate.
• Support patient and family plans.
• Make referrals for follow-up.
• Serve as a role model.

• Provide basic hygiene, skin care.
• Perform routine nursing activities.
• Detect change from baseline data.
• Reorganize abnormal responses.
• Provide independent and dependent treatment.
• Assist with ADLs.
• Provide appropriate sensory stimulation.
• Mobilize equipment.
• Maintain equipment.
• Use special abilities or talents.