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NSG403 Terminology

National University: Nursing Theory Jan 2014

Clinical Decision Making critical thinking skills to obtain relevant info about pt & provide effective care
Nursing process Orderly 5part approach: Assessment - collection pt's problems & needs Problem identification - obtained from assessment Planning - pt centered goal, best way to reach Intervention - optimum courses action for goal Evaluation - plan reach goals?
prognosis predition dz course & end of dz, estimated chance of recovery
assessment analysis resources necessary to solve administrative/clinical problem
Nursing Health History data about pt's present level of wellness, changes in life patterns, socio-cultural role, mental and emotional reactions to illness
objective data info from observation or quantifiable test results
subjective data pt's perception, understanding and interpretation of clinical data
nursing diagnosis pt problem identified needing intervention - compare analysis of assessment to "normal"
Client centered problems What nursing leaders and educators revised their curricula to reflect.
defining characteristics Cluster of signs and symptoms that are observed in the client and that imply a specific nursing diagnosis.
Diagnostic label NANDA International approved nursing dx
etiology study of cause of dz
Medical diagnosis identification of pt's illness/ discomfort
NANDA International Nursing Diagnosis Association - ensures EBP = pt safety increased
related factor condition or etiology identified from pt's assessment data (cause of dz)
risk nursing dx human response to health conditions - processes may develop in vulnerable groups
client-centered goal measurable behavior/response best possible level of pt wellness/independence
collaborative intervention what nurses can ONLY do for pts w/ order of physician/provider (Rx administration/Tx)
Critical pathway Admin. method to organize, evaluate, limit variations in pt care - standardization
dependent nursing intervention require order from physician
expected outcome result of tx
risk factor likelihood experiencing contributing cause in an action
independent nursing intervention Tx able to do w/o direction from physician
long term goal objective achieved over weeks/months
nursing care plan goal/objectives nursing care for pt, and steps to reach goal
priority setting Triage - determining what is most immediate for attention
clinical guideline SOP for that establishment
direct care tx directly with pt
indirect care working for pt w/o direct contact (labs, pharmacy)
implementation Nursing process -> nursing actions are carried out
interdisciplinary care plan care plan outlining contributions of all disciplines
Nursing intervention Nursing Process -> need assessment/plan (includes areas of hygiene, mental & physical comfort)
standing order Providers specification of tx to continue 'till Stop Order placed in chart
outcome condition resulting from health care intervention
outcome management managing the clinical outcomes of clients as a result of tx for performance and effectiveness
afebrile w/o fever (apyretic)
pyretic fever
antipyretics lowers fevers caused by infection, inflammation & neoplasms
blood pressure tension exerted on artery walls due to: strength heart contraction resistance of arterioles & capillaries elasticity of blood vessels blood volume blood viscosity
core temperature body's temperature deep (heart, organs) measured with central venous catheter or pulmonary artery catheter
diaphoresis profuse sweating
eupnea normal respiration
febrile fever
fever abnormally elevated temperature(rectal temp higher)
pyrexia fever
fever of unknown origin fever 3w, dx not established after 1w of hospital investigation
PERRLA Pupils Equal Round Reactive to Light and Accommodation
thermoregulation heat regulation
afterload cardiac - forces impeding flow of blood out of heart
Subjective pain pain scale, changes in appetite,
objective pain observable: guarding behavior protective gestures diaphoresis pupillary dilation
Analgesic relieves pain (Rx & OTC)
Breakthrough Pain pain occurring despite measures taken against it
Chronic pain long-lasting with episodic flares
drug tolerance progressive decrease in effectiveness of a drug
idiopathic pain pertaining to an illness of uncertain/undetermined cause
pain tolerance degree of pain person can withstand
patient controlled analgesia drug administration method where pt controls drug delivery for pain - infusion pump
perception awareness of objects/sensory information
Dysphagia inability/difficulty to swallow
Enteral nutrition EN Provision of nutrients through the gastrointestinal tract when the client cannot ingest, chew, or swallow food but can digest and absorb nutrients
parental nutrition PN administering nutrition bypassing digestive system - into vascular system
peristalsis Coordinated, rhythmic, serial contractions of smooth muscle that force food through the digestive tract.
endoscopy Visualization of the interior of body organs and cavities with an endoscope.
paralytic ileus Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction.
Distention Swelling of a body cavity; may be caused by fluid, gas, or a mass
adverse effect A severe response to medication.
anaphylactic reaction Reactions characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx, and severe wheezing and shortness of breath.
Buccal Of or pertaining to the inside of the cheek or the gum next to the cheek.
idiosyncratic reaction Individual sensitivities to drug effects; caused by inherited or other bodily constitution factors.
infusion Introduction of a substance such as a fluid, drug, electrolyte, or nutrient directly into a vein by means of gravity flow.
inhalation To breathe in or draw in with the breath.
injection Act of forcing a liquid into the body by means of a needle and syringe.
instillation Procedure in which a fluid is slowly introduced into a cavity or passage of the body (e.g., rectum) and allowed to remain for a specific length of time before being withdrawn or drained.
intradermal ID within dermis of skin
intramuscular IM Tissue within the interior of a muscle.
intraocular Eye medication delivery involving inserting a medication, similar to a contact lens, into a client's eye.
intravenous IV Pertaining to the inside of a vein.
irrigation Process of washing out a body cavity or wounded area with a stream of fluid.
Metered-dose Inhalers MDI Inhaler designed to produce local effects such as bronchodilatation.
Narcotics Drug substance, either derived from opium or produced synthetically, that alters perception of pain and that with repeated use may result in physical and psychological dependence.
parenteral administration Injecting a medication into body tissues.
polypharmacy Use of a number of different drugs by a patient who may have one or several health problems. multiple drug use
side effect Any reaction or consequence that results from medication or therapy.
Subcutaneous SubQ Injection into tissues just below the dermis of the skin.
Sublingual SL under tongue
Synergistic effect When two drugs act synergistically, the effect of the two drugs combined is greater than the effect that would be expected if the individual effects of the two drugs acting alone were added together.
Therapeutic effect Desired benefits of a medication, treatment, or procedure.
Toxic effect Resulting from an excess amount of medication in a client's blood, these effects may be caused by the excessive use of medication, overdose, impaired excretion, or idiosyncratic reaction to the medication itself.
Transdermal disk Method of applying medication topically; also known as a patch.
Verbal order Physician's order given to the nurse, usually over the telephone.
Z-track method Technique for injecting irritating preparations into muscle without leaking residual medication through sensitive tissues. skin pulled to side during injection, allowed to return after injection