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NUR101 Mod 1/B
| Term | Definition |
|---|---|
| Assessment | collection and interpretation of data relevant to the health status of a client |
| Planning | identification of nursing interventions and goals for review by the registered nurse. |
| Implementation | delivering nursing care according to an established health care plan and as assigned by the registered nurse |
| Evaluation | participation in determining the extent to which desired outcomes of nursing care are met and in planning for subsequent care |
| Reporting | communication of information to other persons responsible for or involved in the care of the client |
| Recording | documentation of information on the appropriate client record, nursing care plan or other documents. |
| Collaborating | communicating and working cooperatively in implementing the health care plan with individuals whose services may have a direct or indirect effect upon the client's health care |
| Standards of Care | purpose is to protect the patient |
| Criminal Law | offensive to society in general, detrimental to society as a whole, Involves public offenses |
| Civil Law | violates a person’s rights, detrimental to that individual, offense that is against an individual |
| Liability | legal responsibility |
| Informed Consent | Full disclosure of the facts the patient needs to know to make an intelligent decision before any invasive treatment or procedure. Nurse is the witness |
| Abandonment of care | Wrongful termination of providing patient care |
| Assault | An intentional threat to cause bodily harm to another; does not have to include actual bodily contact |
| Battery | Unlawful touching of another person without informed consent |
| Defamation | Spoken or written statements made maliciously and intentionally that may injure the subject's reputation |
| Slander | Malicious or untrue spoken words about another person that are brought to the attention of others |
| Libel | A malicious or untrue writing about another person that is brought to the attention of others |
| Competency | legal presumption that a person of legal age can make a decision for his or herself unless proven otherwise |
| Tort | type of civil law that involves wrongs against a person or property, torts include negligence, assault, battery, defamation, fraud, false imprisonment, and invasion of privacy |
| Negligence | failure to act as a reasonably prudent person would act in similar circumstances, with similar education, or would not act in similar circumstances |
| Reasonably Prudent Man Theory | A standard that requires an individual to perform a task as any “reasonably prudent man of ordinary prudence, with comparable education, skill, and training under similar circumstances” would perform that same function. |
| Malpractice | specific type of negligence, Inadequate/inappropriate practice, Has to be related to a profession |
| Assigning Care | Transfer or both responsibility and accountability of an activity from one individual to another |
| Delegating Care | Delegating-Transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome |
| Five Rights of Delegation | Right person, Right task, Right circumstance, Right directions/communication, Right supervision |
| Ethics | refers to values that influence a person’s behavior and the individual’s feelings and beliefs about what is right or wrong |
| Ethical dilemmas | Situations that do not have a clear right or wrong answer |
| Respect for persons | Each patient has the same worth as another and is always entitled to respect, |
| Autonomy | Personal freedom of choice |
| Beneficence | Nurse must promote the well-being of all patients |
| Nonmaleficence | To do no harm Nurse has a ethical and legal duty to prevent harm to a patient |
| Justice | The concept of what is fair All patients have the same right to nursing care |
| Refusal to Treat | The nurse cannot refuse to care for a patient because she disagrees with the decisions the patient makes |
| Dignity | Allowing and honoring the patient’s possession of self-respect |
| Golden Rule | Treat every patient as you would want to be treated yourself or as you would want the most important person in your life to be treated |
| Health Insurance Portability and Accountability Act | The main purpose is to protect the patient health care information |
| Protected Health Information | any health information that can be used to identify a patient and their past, present, or future physical or mental health or condition of the patient, healthcare services provided to the patient, or the payment for these services |
| Advanced Directives | provides specific instructions for healthcare workers in the event the patient is unable to make the decisions at the time |
| Incident Reports | Used to document any event not consistent with the routine operation of a healthcare unit or the routine care of a patient |
| Exception to a Patient’s Right to Privacy | Suspected abuse , communicable diseases, gunshot wound |
Created by:
Ms. A LPNI
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