Sheri 2013
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| Acute Care | a branch of secondary (or tertiary) health care where a patient receives active but short-term treatment usually more costly
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| Adult Day Care Centers | provide a variety of health and social services to specific client populations who live alone or with family in the community
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| Assisted living | an attractive long term care setting with a homier environment and greater resident autonomy
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| Capitation | providers received a fixed amount per client or enrollee of a health care plan
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| Case management | a case manager, coordinates the efforts of all disciplines to achieve the most efficient and appropriate plan of care for the client
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| Client-centered care | Putting clients first is key to improving the quality of health and family planning services. Planners, managers, and providers can design and offer services that both meet medical standards and treat clients as they want to be treated.
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| Critical pathway | a multidisciplinary treatment plan that outlines the treatments or interventions plan that outlines the treatments or interventions clients need to have while int eh hospital or a specific condition or procedure
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| Professional standards review organization | review the quality, quantity, and cost of hospital care
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| Utilization review committees | review the admissions, diagnostic testing, and treatments provided by physicians who cared for clients receiving Medicare
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| Prospective payment system | eliminated cost-based reimbursement. Hospitals serving clients who received Medicare benefits were no longer able to charge whatever the client's care cost
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| resource utilization groups | mutually exclusive categories that reflect
levels of resource need in long-term care settings,
primarily to facilitate Medicare and Medicaid payment
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| Managed care | health care systems in which there is administrative control over primary health care services for a defined client population. The provider or health care system receives a predetermined capitated payment for each enrolled in the program
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| Intergrated deliery networks | a set of providers and services organized to deliver continuum of care to a population of clients at a capitated cost in a particular setting.
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| Medicare | Program designed to cover health care costs for senior citizens
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| Preferred provider Organization | Limits an enrollee's choice to a list of "preferred" hospitals, physicians, and providers. An enrollee pays more out of pocket expenses for using a provider not on the list
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| Exclusive provider organization | One that limits an enrollee's choice to providers belonging to one organization.
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| Medicaid | Federally funded, state operated program that provides: (1) health insurance to low income families (2) health assistance to low-income people with long term care disabilities (3) supplemental coverage and LTC assistance to older adults and Medicare benef
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| Private insurance | Traditional fee-for-service plan. Payment computed after client received services on basis of number of services used.
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| Long term care insurance | supplemental insurance for coverage of long-term care services.
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| Disease prevention | activities that protect people from becoming ill because of actual or potential health threats
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| Health promotion | activities that develop human attitudes and behaviors to maintain or enhance well-being
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| Primary care | provision of integrated, accessible health care services by health care professionals who address a majority of personal health care needs, develop partnerships with clients, and care for families and communities
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| Primary health care | combination of primary and public health care that is accessible to individuals and families in a community provided at an affordable cost
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| Primary prevention | health promoting behaviors or activities that reduce the occurrence of an illness
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| Public Health | community and interdisciplinary care aimed at preventing disease and promoting health
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| secondary prevention | early diagnosis and treatment of illness
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| tertiary prevention | care that prevents further progression of disease
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| discharge planning | begins at the moment a client is admitted to a health care facility. A process used to decide what a patient needs for a smooth move from one level of care to another
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| rehabilitation | restores a person to the fullest physical, mental, social, vocational, and economic potential possible
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| Home care | provision of medically related professional and paraprofessional services and equipment to clients and families in their homes for health maintenance, education, illness prevention, diagnosis, and treatment of disease
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| work redsign | more services available on nursing units, thus minimizing the need to transfer and transport clients across multiple diagnostic and treatment areas
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| restorative care | help individuals regain maximal functional status and to enhance quality of life through promotion of independence and self-care
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| extended care facilities | provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities
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| Skilled nursing facility | offers skilled care from a licensed nursing staff
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| minimum data set | part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff
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| Respite care | a service that provides short-term relief or time off for a person providing home care to an ill, disabled, or frail older adult
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| Hospice | system of family centered care that allows clients to live and remain at home with comfort
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| Nursing sensitive outcomes | client outcomes that are directly related to nursing care.
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| Globalization | Advances in communication, primarily through the internet, allow nurses, clients and other health care providers to talk to others worldwide about health care issues
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| Nursing informatics | combines the best of computer science and information science with nursing science. It supports nursing practice and delivery of nursing care by providing nurses with a way to manage and process nursing data
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| Vulnerable population | Children, women, and older adults that are most threatened by urbanization.
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| Confidentiality | is how health care providers treat client private information once it has been disclosed to others
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| DPAHC (Durable Power of Attorney for Health Care) | A legal document that designates a person or persons of one's choosing to make health care decisions when the client is no longer able to make decisions on his or her own behalf
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| Accreditation | Accreditation agencies such as The Joint Commission (TJC) specify guidelines for documentation
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| Acuity records | offer a way to determine the hours of care and staff required for a given group of clients
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| Case Management Model | incorporates a multidisciplinary approach to documenting client care
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| Change-of-shift report | participation between staff members from both shifts where a nurse gives orally in person, by audiotape recording, or during "walking-planning" to share and clarify information about patient
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| Charting by exception | focuses on documenting deviations from the established norm or abnormal findings
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| Computerized Physician Order Entry | one type of order entry system gaining popularity in the larger medical centers across the country
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| Consultations | another form of discussion whereby one professional caregiver gives formal advice about the care of a client to another caregiver
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| Critical Pathways | are multidisciplinary care plans that include client problems, key interventions and expected outcomes within an established time frame
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| DAR | (Focus Charting)
D- Data
A- Action
R- Response
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| Diagnosis-related Group | is a series of decision trees designed to cluster groups of clients together by diagnosis, surgical procedures, complications, preexisting illness and age
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| Documentation | any written or printed yo rely on as record or proof for authorized persons
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| Flow Sheets | forms that allow nurses to quickly and easily enter assessment data about the client, including vital signs and routine repetitive care
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| Focus Charting | Use of DAR, moves away from charting only problems and instead addresses a client concerns
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| sign | symptom, a condition, a nursing diagnosis, a behavior, a significant event, or a change in a client's condition
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| Information Technology | refers to the management and processing of info, generally with the assistance of computers
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| Kardex | a portable "flip-over" file or notebook, is kept at the nurses station includes: basic demographic data, HIPAA code word, Physician's name, primary medical diagnosis, current treatment orders from health care providers to be carried out by the nurse, care
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| Menu | lists related commands that the nurse selects from the computer screen to complete the client assessment
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| Nursing Informatics | defined by the ANA (American Nurse Association) as a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
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| Password | a collection of alphanumeric characters that a user types into the computer before accessing a program
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| PIE | (Progress method)
P- Problem
I- Intervention
E- Evaluation
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| Problem-Orientated Medical Record (POMR) | a method of documentation that emphasizes the client's problem
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| Record | aka chart is a confidential , permanent legal documentation or information relevant to a client's health care
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| Referrals | an arrangement for services by another care provider
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| Reports | oral, written, or audiotaped exchanges of information between caregivers
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| Residents | name given to patients who require long-term health care and will live the rest of their life in a long-term care setting
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| SOAP | (Progress method)
S- Subjective
O- Objective
A- Assessment
P- Plan
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| SOAPIE | (Progressive method)
S- Subjective
O- Objective
A- Assessment
P- Plan
I- Intervention
E- Evaluation
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| Source Record | The client's chart has a separate section for each discipline to record data allows caregivers to easily locate the proper section of the record to make entries in
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| Standardized Care Plans | preprinted, established guidelines that are used to care for clients who have similar health problems
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| Transfer Reports | Promotes continuity of care between one unit to another about a patients information
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| Variances | Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway time frame
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| Evidence based practice | a problem solving approach to clinical practice that intergrates the conscience use of best evidence in combination with a clinicians expertise and client preferences and values in making decisions about client care
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| PICO question | 4 focused questions, to search for evidence in scientific literature
P- patient population of interest
I- Intervention of interest
C- comparisons of interest
O- outcome
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| peer reviewed | a panel of experts familiar with the articles topis or subject matter has reveiwed the article
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| clinical guidlines | systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific client population
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| Bias | controlled trials without randomized studies
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| hypotheses | predictions made about the relationship or difference between study concepts
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| variables | concepts, characteristics, or traits that vary within subjects
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| nursing research | a way to identify new knowledge, improve professional education and practice, and use research effectively
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| scientific method | the foundation of research and the most reliable and objective of all methods of gaining knowledge
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| empirical data | evidence that is part of experience
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| quantitative nursing research | a study of nursing phenomena the offeres precise measurment and qualification
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| experimental research | conditions are tightly controlled to eliminate bias and to ensure that findings can be generalizable to similar groups of subjects
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| surveys | obtain information from populations regarding the frequency, distribution, and interrelations of variables among subjects in the study
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| evaluation research | a forms of quantitive research that involves finding out how well a program, practice, procedure, or policy is working
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| Qualitative nursing research | the study of phenomena that are difficult to quantify or characterize
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| inductive reasoning | develop generalizations or theories from specific observations or interviews
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| research process | an orderly series of steps that allow a researcher to move from asking the research questions to finding the answer
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| Informed consent | research subjects (1) are given full and complete information about the purpose of the study, procedures, data collections, potential harm and benefits, and alternative methods of treatment (2) are capale of fully understanding the research and the implic
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| anonymity | occurs when even the researcher cannot link the subject to the data
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| confidentiality | guarentees that any information that subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team
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| performance improvement | an organization analyzes and evaluates current performance to use results to develop focused improvement actions
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| quality improvement | an approach to the continued study and improvement of the process providing health care services to meet the needs of clients and others
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| active listening | being attentive to what the client is saying both verbally and nonverbally
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| assertiveness | conveys a sense of self-assurance while also communicating respect for the other person
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| autonomy | the ability to be self directed and independent in accomplishing goals and advocating for others
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| channels | means of conveying and receiving messages through visual, auditory and tactile senses
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| communication | a lifelong learning process for the nurse
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| empathy | the ability to understand and accept another person's reality, to accurately perceive feelings, and to communicate this understanding to the other
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| environment | the setting for sender-receiver interaction
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| feedback | the message the receiver returns
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| interpersonal communication | one-to-one interaction between the nurse and another person that often occurs face to face
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| interpersonal variables | factors within both the sender and receiver that influence communication
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| intrapersonal communication | a powerful form of communication that occurs within an individual - self-talk, self-verbalization, inner thought
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| message | the content of communication
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| metacommunication | broad term that refers to all factors that influence communication
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| nonverbal communication | includes all five senses and everything that does not involve the spoken or written word
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| perceptions | informaiton received through the five senses of sight, hearing, taste, touch, and smell
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| perceptual biases | human tendencies that interfere with accurately perceiving and interpreting messages from others
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| public communication | interaction with an audience
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| receiver | the person who receives and decodes the message
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| referent | motivates one person to communicate with another
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| sender | person who encodes and delivers the message
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| small group communication | interaction that occurs when a small number of persons meet together
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| symbolic communication | the verbal and nonverbal symbolism used by others to convey meaning
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| sympathy | concern, sorrow, or pity felt for the client generated by the nurse's personal identification with the client's needs
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| therapeutic communications techniques | specific responses that encourage the expression of feelings and ideas and convey acceptance and respect
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| transpersonal communications | interaction that occurs within a person's spiritual domain
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| verbal communications | uses spoken or written words
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| affective learning | expression of feelings and acceptance of attitudes, opinions, or values
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| analogies | supplement verbal instructions with familiar images that make complex information more real and understandable
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| cognitive learning | includes all intellectual behaviors and requires thinking
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| compliance | a client's adherence to the prescribed cours of therapy
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| functional illiteracy | the inability to read above a fifth grade level
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| learning | the purposeful acquisition of new knowledge, attitudes, behaviors, and skills
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| learning objective | what the learner will be able to do after successful instruction
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| motivation | a force that acts on or within a person
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| psychomotor learning | aquiring skills that require the integration of mental and muscular activity, such as the ability to walk or to use an eating utensil
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| reinforcement | requires using stimulus that increases the probability for a response
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| return demonstration | learners first observe the teacher and then have the chance to practice the skill
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| self efficacy | a person's perceived ability to successfully complete a task
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| teaching | an interactive process that promotes learning
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| Anabolism | the building of more complex biochemical substance by synthesis of nutrients
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| Anorexia | loss of appetite
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| Anthropometry | measurement system of the size and makeup of the body height and weight obtained
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| Basal Metabolic Rate (BMR) | the energy needed to maintain life-sustaining activities (breathing, circulation, heart rate, and temperature)
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| Body Mass Index (BMI) | measures weight corrected for height and serves as an alternative to traditional height-weight relationships
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| Catabolism | the breakdown of biochemical substance into simpler substances
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| Chyme | acidic and liquefied mass that enters the duodenum
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| Daily Values | nutrient standards that are printed on food labels. Based on nutrient and energy recommendations for a general 2,000-calorie diet, they allow consumers to compare the nutrient and energy contents of packaged foods.
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| Dietary Reference Intakes (DRIs) | evidence-based criteria for an acceptable range of amounts of vitamins and nutrients to avoid deficiencies or toxicities for each gender and age-group
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| Dysphagia | difficulty when swallowing
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| Enteral Nutrition (EN) | nutrients given in the GI tract. EN receive formula via nasogastric, jejunal or gastric tubes
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| Hypervitaminosis | of fat-soluble vitamins results from megadoses (intentional or unintentional) of supplemental vitamins, excessive amounts in fortified foods and large intake of fish oils
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| Ideal Body Weight (IBW) | provides an estimate of what a person should weigh
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| Kilocalorie | a unit of energy equal to 1000 calories
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| Malabsorption | abnormal absorption of nutrients from the digestive tract i.e Celiac Disease
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| Malnutrition | a state of poor nutrition
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| Medical Nutrition Therapy (MNT) | use of specific nutritional therapies to treat an illness, injury, or condition it's necessary to assist the body's ability to metabolize certain nutrients, correct nutritional deficiencies related to the disease, and eliminate foods that may exacerbate d
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| Metabolism | refers to all the biochemical reactions within the cells of the body
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| Nutrient Density | the proportion of essential nutrients to the number of kilocalories
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| Nutritients | elements necessary for body processes and function
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| Parenteral Nutrition | a form of specialized nutrition support in which nutrients are provided intravenously
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| Peristalsis | within the esophagus are wavelike muscular contractions that move food to the base of the esophagus above the cardiac sphincter
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| Resting Energy Expenditure (REE) | the amount of energy an individual needs to consume over a 24 hour period for the body to maintain all its internal working activities while at rest
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| Vegetarianism | consumption of a diet consisting predominantly of plant foods
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| Water Soluble vitamins | vitamin C and the B complex (eight vitamins) The body does not store these vitamins so they need to be provided in the daily food intake
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| Fat Soluble Vitamins | Vitamins A,D,E and K are stored in the fatty compartments of the body, all taken in through dietary intake except for D which is taken in by sun exposure
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| Anorexia Nervosa | a disorder in which the irrational fear of becoming obese results in severe weight loss from self-imposed starvation
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