vocab
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| actual diagnosis | diagnosis A human response to a health condition or life process that is happening at the present time.
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| assessment | The systematic and ongoing collection of comprehensive data relevant to a patient’s health or to the situation or ambience influencing the patient’s health.
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| audit | A record or chart review
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| baseline data | baseline data
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| defining characteristics | The manifestations, or signs and symptoms, of a diagnosis.
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| dependent interventions | interventions Nursing interventions that are ordered by a physician or carried out under a physician’s supervision for the treatment of a medical diagnosis.
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| diagnosis | A clinical judgment about the client’s response to actual or potential health conditions or needs
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| emergency nursing assessment | The data collection process that occurs in a life-threatening situation.
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| evaluation | The process of determining both the client’s progress toward the attainment of expected outcomes and the effectiveness of nursing care.
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| focused health data assessment | The performance of selected portions of the patient history and examination process whenever specific conditions warrant this action
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| health promotion diagnosis | diagnosis A diagnosis that reflects a clinical judgment that increases the patient’s motivation to enhance specific health-supporting behaviors
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| implementation | The process of carrying out the plan of care, which may include any or all of the following activities: providing, monitoring, delegating, coordinating, teaching, and counseling.
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| independent interventions | Nursing interventions that are initiated by the nurse and that address nursing diagnoses.
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| Maslow’s hierarchy of needs | A tool for prioritizing nursing diagnoses; according to this hierarchy, a patient’s basic physical needs must be met before his or her safety needs, then social needs, then esteem needs, then selfactualization needs.
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| nursing | The protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and popu
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| nursing process | A process for the delivery of nursing care that involves the following steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation
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| objective data | Signs or observations made directly by the nurse that are capable of being verified by another person
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| outcome evaluation | An examination of quality indicators such as number of patient falls, number of new pressure ulcers formed, number of postoperative wound infections, and number of tube-fed patients developing aspiration pneumonia
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| outcomes identification | The identification of expected care outcomes that are individualized according to the patient’s presenting needs or diagnoses or to the situation in which the patient is found.
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| planning | The process of developing a plan of care and prescribing strategies designed to achieve the expected outcomes
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| policies | Written instructions designed to address a commonly occurring problem in an institutionally approved manner
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| possible diagnosis | A diagnosis that is being investigated but has not yet been confirmed.
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| primary data | Data that the nurse derives directly from interaction with the patient
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| procedures | Institutionally approved, preprinted, detailed instructions on how to perform specific clinical tasks.
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| process | The appropriateness of the care given and whether policies and procedures were followed to maximize patient safety, minimize medication error, minimize infectious contamination, and ensure that patients and families feel welcome.
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| protocols | Institutionally approved, preprinted instructions governing interventions or actions to be taken in the care of groups of patients with particular problems.
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| quality improvement (QI) | Methods that focus on diagnosing system problems and suggesting interventions to address those problems.
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| risk diagnosis | A diagnosis that, given the right conditions, has a high probability of occurring in a vulnerable person, family, group, or community.
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| risk factors | Those variables that increase a patient’s vulnerability to developing an actual nursing diagnosis.
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| secondary data | Data derived from sources other than direct interaction with the patient.
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| standing orders | Institutionally and departmentally approved instructions granting the nurse the authority to act in the absence of a physician.
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| state nurse practice act | A legal act that regulates the practice of nursing within each state
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| structure | The setting or the environment in which care is given.
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| subjective data | Data that relies on a conscious patient providing a narrative statement or report.
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| syndrome diagnosis | A diagnosis that describes a clinical judgment that uses at least two nursing diagnoses.
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| terminal evaluation | Evaluation of patient outcomes prior to discharge of the patient from the hospital or prior to a case being closed in a community setting.
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| time-lapsed nursing assessment | A repeated assessment obtained to compare data collected at one or more points in time with baseline dat
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| activities of daily living (ADL | The basic self-care tasks of living, including feeding and eating, bathing and hygiene, dressing and grooming, toileting and continence, and moving and transferring.
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| adaptive model | A model of health, wellness, and illness that views health as adaptation to the physical and social world in which a person lives and disease as maladaptation to this world
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| agent | The substance that causes a disease.
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| alarm reaction | The flight-or-fight response, which is the first portion of the response-based stress model and is mediated by the sympathetic nervous system
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| auscultation | Listening to sounds emitted from the patient’s heart, arteries, respiratory tract, or intestinal tract, typically through use of a stethoscope
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| biofeedback | A process by which the body learns to bring autonomic nervous system responses under its contro
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| clinical mode | A model of health, wellness, and illness that narrowly defines health as the absence of disease.
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| concrete imagery | A form of imagery that involves the creation of realistic images that are physically and physiologically correct
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| countershock phase | The second phase of the alarm reaction, during which the physiological changes that occurred during the shock phase reverse themselves
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| disease | A specific pathological state with defined signs and symptom
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| end-state imagery | A form of imagery that involves picturing the final state of a process or situation
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| environment | The surroundings in which both a disease-causing agent and an affected host exist.
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| eudemonistic model |
A model of health, wellness, and illness that focuses on health as well-being, self-fulfillment, and self-actualization
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| exhaustion phase | The final phase of the response-based stress model, which occurs if the resistance phase is unsuccessful; during this phase, the body either rests and recovers, or death occurs.
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| general adaptation syndrome (GAS | The bodily response to stress that involves the adrenal and lymphatic structures and the gastrointestinal tract
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| guided imagery | Imagery that is led by a therapist in person or on tape
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| health behaviors | Actions taken to promote health, protect health, or prevent illness and disease
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| health beliefs | person’s health-related convictions.
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| health status | A person’s health state or condition at one particular point in time
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| Healthy People 2020 |
The nation’s disease-prevention and health-promotion agenda, which is coordinated by the United States Department of Health and Human Services, Office of Disease Prevention and Health Promotion
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| host | The person, animal, or insect that is affected by a disease.
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| hypnosis | A method of altering consciousness by focusing attention on one thought, thereby distracting consciousness from other thoughts.
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| illness | An unhealthy state or condition of the mind or body in which physical, social, emotional, intellectual, or spiritual functioning is compromised.
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| imagery | A stress-reducing technique in which the patient produces mental images
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| inspection | The systematic, primarily visual examination of a body part or structur
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| instrumental activities of daily living (IADL |
Tasks involving the basic tools or instruments of daily life needed to live independently; these include the ability to use a telephone, prepare meals, launder clothes, clean house, take medicine, and handle finances
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| local adaptation syndrome (LAS | A bodily response to stress that involves only one organ acting alone
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| meditation | An altered state of consciousness in which the mind is focused in passive attention and quiet, resulting in an experience of transcendence
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| music therapy | Use of beat, rhythm, pitch, harmony, synchrony, chords, and lyrics to facilitate healing, alter consciousness, reduce stress, facilitate movement, aid sleep, improve concentration, and more.
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| palpation | Touching the patient with the pads of the fingers to detect vibrations or discriminating changes in texture or consistency
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| percussion | Using the fingers to tap the patient’s body lightly but sharply
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| primary prevention |
Preventing illness and disease before it occurs.
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| process imagery | A form of imagery in which a procedure or process is mentally rehearsed in a calm and relaxed atmosphere
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| progressive relaxation | relaxation
A stress-reducing technique in which the patient progressively tenses and relaxes each muscle group, concentrating on the differences between feelings of tension and feelings of relaxation.
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| resistance phase | The phase of the response-based stress model during which the body attempts to cope with the stressor.
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| response-based stress model | The model of stress and adaptation in which stress is considered to be a response
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| role performance model | A model of health, wellness, and illness that views health in functional terms; here, if a person can function, he or she is healthy
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| secondary prevention |
Detecting and treating diseases and health problems in their earliest stages
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| shock phase | The first phase of the alarm reaction, during which epinephrine and cortisone are released and the body prepares itself for flight or fight.
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| sickness | The opposite of wellness; a state of not being wel
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| stimulus-based stress mode |
The model of stress and adaptation in which stress is defined as a stimulus.
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| stress | The forces or stimuli that impinge upon an individual; also, an individual’s response to these forces
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| stressors | Another name for the forces or stimuli that cause stress.
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| symbolic imagery | A form of imagery that involves picturing an abstract situation in order to symbolically represent a real-life situation
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| tertiary prevention | Restoring, maintaining, and maximizing health and optimizing functioning in the later stages of illness or disease
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| transaction-based model of stres | The model of stress and adaptation in which a person’s response to an environmental stimulus is either blocked or facilitated by a variety of factors, such as the sensitivity of the person to stress and the person’s vulnerability at any one point in time
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| wellness | The process of making healthy lifestyle choices daily to maximize one’s health potential
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| yoga | A system of beliefs and practices aimed at the union of the individual self with the universal sel
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| adaptive equipment | Equipment that is intended to assist a person in dealing with limitation and risk by modifying the environment
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| CLAS standards | A set of fourteen National Culturally and Linguistically Appropriate Services (CLAS) standards that address culturally competent care, language access services, and organizational supports for cultural competence.
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| elbow restraints | Restraints used in the care of infants or small children to prevent flexing an arm to scratch or touch skin on the face or head, primarily during surgery
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| environment | The sum of the physical and psychological factors that influence life and survival
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| hazard | A condition or phenomenon that increases the risk of injury
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| Hendrich II Fall Risk Model | A fall risk assessment that targets older adults at risk of falling within an acute care environment
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| injury | A sustained hurt, damage, or loss.
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| internal risk factor | factors
Internal variables that increase a person’s vulnerability to injury.
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| limb restraints | Restraints placed on a patient’s ankle or wrist to restrict movement in a limb during IV infusions
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| mitts/hand restraint |
Restraints placed on a patient’s hand to prevent the patient from scratching and injuring himself or herself.
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| mummy restraint | A blanket wrapped in a special way to enclose a child’s body to prevent movement during a procedure.
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| Omnibus Budget Reconciliation Act (OBRA) | A federal law passed in 1987 that, among other things, states that nursing home residents have the right to be free from physical or chemical restraints that are not required to treat specific medical symptoms.
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| para-aminobenzoic acid (PABA) | aminobenzoic acid (PABA)
A substance frequently included in sunscreens that increases their effectiveness.
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| RACE | An acronym that can help nurses remember the appropriate steps for dealing with a fire: (1) rescue and remove clients who are in immediate danger, (2) activate the fire alarm, (3) confine the fire, and (4) extinguish the fire
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| risk of injury | The probability or chance of injury due to factors internal and external to the individual.
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| safe environment | An environment in which the kind and number of hazards are reduced and accidents are prevented
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| safety | The freedom from risk of injury
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| safety straps/belts | Restraints placed around a client’s waist and secured in the back of a wheelchair or stretcher to protect the client from falling while he or she is being move
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| sunscreen protection factor (SPF | A number that indicates how long a person who applies a particular sunscreen may remain in the sun before burning.
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| ultraviolet A | (UVA)
Longer waves of ultraviolet light that are responsible primarily for photosensitivity, photoallergic, or phototoxic reactions
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| ultraviolet B | (UVB)
Shorter waves of ultraviolet light that are responsible primarily for burning, tanning, and skin cancer.
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| vest restraints | Restraints that consist of a sleeveless jacket with tails; the tails are tied to the bed frame under the mattress or to the back of a chair.
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