Glossary Terms from All Chapters in The Nursing Process Unit
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| Term | Definition
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| functional health patterns | "Method for organizing assessment data based on the level of client function in specific areas (e.g.
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| assessment | "First step of the nursing process. Activities required in the first step are data collection
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| back channeling | Active listening techniques that indicate that the nurse has heard what the client says.
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| interview | Type of communication with a client that is initiated for a specific purpose and focused on a specific content area.
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| nursing health history | "Data collected about a client's present level of wellness
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| objective data | Data relating to a client's health problem that are obtained through observation or diagnostic measurements.
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| open-ended questions | Inquiries aimed at obtaining a full client response and discussion between the client and the nurse.
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| review of systems | Systematic method for collecting data on all body systems.
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| standards | Measure or guide that serves as a basis for comparison when evaluating similar phenomena or substances.
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| subjective data | Data relating to a client's health problem that are given in the client's own words.
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| cue | Information that you obtain through use of the senses
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| data analysis | A process of reviewing available data for patterns or trends and forming conclusions about the meaning of the data.
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| validation | The process of comparing data with another source to confirm its accuracy
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| expected outcome | "Likely condition of a client at the end of therapy or of a disease process
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| goals | "Desired results of nursing actions
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| long-term goal | "Objective that is expected to be achieved over a longer period of time
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| nursing care plan | "Written guidelines of nursing care that document specific nursing diagnoses for the client and goals
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| planning | Process of designing interventions to achieve the goals and outcomes of health care delivery.
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| scientific rationale | Reason for choosing a specific nursing action that is based on supporting literature.
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| short-term goal | "Objective that is expected to be achieved in a short period of time
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| client-centered goal | A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function.
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| collaborative intervention | "Therapies that require the combined knowledge
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| dependent nursing intervention | Those actions that require an order from a physician or another health care professional
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| nurse-sensitive client outcome | "Individual
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| priority setting | "The order of nursing diagnoses using notations of urgency and/or importance
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| independent nursing intervention | Actions that a nurse initiates without direction from a physician or other health care professional.
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| adverse reaction | "Harmful or unintended effect of a medication
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| client adherence | "Refers to the degree to which the client
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| counseling | "Implementation method that helps the client use a problem-solving process to recognize and manage stress and that facilitates interpersonal relationships between the client and the family
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| direct care | Treatments preformed through interaction with the client.
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| indirect care | Treatments performed away from the client but on behalf of the client or group of clients.
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| interdisciplinary care plans | Plans that represent the contributions of all disciplines caring for the client.
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| lifesaving measure | Implemented when a client's physiological or psychological state is threatened.
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| nursing intervention | Any action by a nurse that implements the nursing care plan or any specific objective of the plan.
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| preventive nursing actions | Interventions directed toward preventing illness and promoting health to avoid the need for secondary or tertiary health care.
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| standing order | "Written and approved document containing rules
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| clinical guideline | A document that guides decisions and interventions for specific health care problems or conditions
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| implementation | "The fourth step of the nursing process
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| evaluation | Category of nursing behavior in which a determination is made and recorded regarding the extent to which the client's goals have been met.
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| functional nursing | Division of tasks in which one nurse assumes responsibility for certain tasks while another nurse assumes responsibility for others.
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| outcomes management | A term that encompasses managing the individual clinical outcomes of clients as a result of prescribed treatments to the formal measurement of system level performance and effectiveness.
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| performance improvement | Term interchangable with quality improvement that describes and approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others.
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| nursing | Diagnosis and treatment of human responses to actual or potential health problems.
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| accrediting (accreditation) | "Process whereby a professional association or nongovernmental body grants recognition to a school or institution for its demonstrated ability in a special area of practice or training
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| acuity recording | Mechanism by which entries describing client care activities are made over a 24-hour period. The activities are then translated into a rating score or acuity score that allows for a comparison of clients who vary by severity of illness.
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| change-of-shift report | Report that occur between two scheduled nursing work shifts. Nurses communicate information about their assigned clients to nurses working on the next shift of duty.
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| charting by exception | Charting methodology in which data is entered only when there is an exception from what is normal or expected; reduces time spent documenting.
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| DAR | "A type of documentation note that includes D—data (both subjective and objective)
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| documentation | Act of authenticating events or activities by keeping written records.
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| flow sheets | Documents on which frequent observations or specific measurements are recorded.
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| focus charting | "Charting methodology for structuring progress notes according to the focus of the note (e.g.
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| problem-oriented medical record (POMR or POR) | Method of recording data about the health status of a client that fosters a collaborative problem-solving approach by all members of the health care team.
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| record | Written form of communication that permanently documents information relevant to health care management.
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| reports | "Transfer of information from the nurses on one shift to the nurses on the following shift. Report may also be given by one of the members of the nursing team to another health care provider (e.g.
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| residents | Individual clients who reside in a long-term care facility.
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| SOAP | "Acronym for subjective
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| SOAPIE | "Acronym for subjective
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| source record | Method for organizing a client's health care record by placing information in sections organized for each discipline that cares for the client.
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| standardized care plans | "Preprinted
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| transfer reports | Verbal report exchanged between care providers when a client is moved from one nursing unit or health care setting to another. The report includes information necessary to maintain a consistent level of care from one setting to another.
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| PIE | Acronym for Problem-Intervention-Evaluation method of charting
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| referrals | Arrangements for services by another care provider
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| variances | "Unexpected outcomes
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| diagnosis-related groups (DRGs) | Groups of clients classified for purposes of measuring a hospital's delivery of care.
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| implantation | "Process involving the attachment
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| inference | Taking one proposition as a given and guessing that another proposition follows.
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| nursing process | "Systematic problem-solving method by which nurses individualize care for each client. The five steps of the nursing process are assessment
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| acromegaly | "Chronic metabolic condition caused by overproduction of growth hormone and characterized by gradual
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| adventitious sounds | Abnormal lung sounds heard with auscultation.
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| aneurysm | "Localized dilation of the wall of a blood vessel
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| apical impulse | Point at which the apex of the heart touches the anterior chest wall; best site for auscultation of heart sounds; also called the point of maximal impulse (PMI).
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| arcus senilis | Thin white ring along the margin of the iris.
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| atherosclerosis | "Common arterial disorder characterized by yellowish plaques of cholesterol
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| atrophied | Wasting or diminution of size or physiological activity of a part of the body caused by disease or other influences.
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| basal cell carcinoma | "Malignant epithelial cell tumor that begins as a papule and enlarges peripherally
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| borborygmi | Audible abdominal sound produced by hyperactive intestinal peristalsis.
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| bronchophony | "Increase in intensity and clarity of the vocal resonance that may result from an increase in the lung tissue density
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| bruit | "Abnormal sound or murmur heard while auscultating an organ
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| chancre | "Small open ulcer that drains serous material; found on genitalia
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| cherry angiomas | Ruby red papules of the skin.
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| cholecystitis | Inflammation of the gallbladder; may be acute or chronic.
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| cirrhosis | Chronic degenerative disease of the liver.
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| clubbing | Bulging of the tissues at the nail base due to insufficient oxygenation at the periphery resulting from conditions such as chronic emphysema and congenital heart disease.
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| conjunctivitis | Highly contagious eye infection; the crusty drainage that collects on eyelid margins can easily spread from one eye to the other.
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| dermatitis | "Inflammation of skin characterized by itching
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| distention | "Swelling of a body cavity; may be caused by fluid
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| ectropion | Eversion of the eyelid that exposes the conjunctival membrane and part of the eyeball.
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| eczema | Superficial dermatitis of unknown cause.
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| entropion | Condition in which the eyelid turns inward toward the eye.
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| erythema | Redness or inflammation of the skin or mucous membranes that is a result of dilation and congestion of superficial capillaries; sunburn is an example.
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| exophthalmos | Abnormal protrusion of one or both eyeballs.
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| exostosis | Abnormal benign growth on the surface of a bone.
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| goniometer | Device that measures the precise degree of motion in a particular joint and is used mainly in clients who have a suspected reduction in joint movement. The instrument has two flexible arms with a 180-degree protractor in the center.
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| hepatitis | Inflammatory condition of the liver.
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| hirsutism | "Excessive body hair in a masculine distribution caused by heredity
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| hydrocephalus | Abnormal accumulation of cerebrospinal fluid in the ventricles of the brain.
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| hypertonicity | Increased muscle tone.
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| hypotonicity | Low muscle tone.
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| indurated | "Hardened tissue
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| integument | "Skin and its appendages: hair
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| jaundice | "Yellow discoloration of the skin
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| kyphosis | Exaggeration of the posterior curvature of the thoracic spine.
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| leukoplakia | "Thick
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| lordosis | Increased lumbar curvature.
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| melanoma | "Group of malignant neoplasms
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| metastasize | To spread.
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| murmur | "Low-pitched fluttering or humming sound
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| nystagmus | "Involuntary rhythmic movements of the eyes; the oscillations may be horizontal
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| occlusion | "Blockage in a canal
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| ophthalmoscope | "Instrument used to illuminate the structures of the eye for the examination of the fundus
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| otoscope | Instrument with a special ear speculum used to examine the deeper structures of the external and middle ear.
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| ototoxicity | Referring to the characteristic of any drug or substance that has a harmful effect on the eighth cranial nerve or the organs of hearing and balance.
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| pancreatitis | Inflammation of the pancreas.
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| Papanicolaou (Pap) test | Painless screening test for cervical cancer; specimens of squamous and columnar cells of the cervix are taken.
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| peritonitis | Inflammation of the peritoneum produced by bacteria or irritating substances introduced into the abdominal cavity by a penetrating wound or perforation of an organ in the gastrointestinal (GI) tract or the reproductive tract.
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| PERRLA | "Acronym for pupils equal
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| petechiae | Tiny purple or red spots that appear on the skin as minute hemorrhages within dermal layers.
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| pigmentation | "Organic coloring material
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| point of maximal impulse (PMI) | Anatomical point along the fourth to fifth intercostal space at the midclavicular line where the heartbeat can most easily be palpated through the chest wall.
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| ptosis | Abnormal condition of one or both upper eyelids in which the eyelid droops; caused by weakness of the levator muscle or paralysis of the third cranial nerve.
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| scoliosis | Lateral spinal curvature.
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| senile keratosis | "Slowly developing
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| stenosis | Abnormal condition characterized by the constriction or narrowing of an opening or passageway in a body structure.
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| syncope | Brief lapse in consciousness caused by transient cerebral hypoxia.
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| tactile fremitus | Tremulous vibration of the chest wall during breathing that is palpable on physical examination.
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| thrill | "Continuous palpable sensation
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| turgor | Normal resiliency of the skin caused by the outward pressure of the cells and interstitial fluid.
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| varicosities | "Superficial veins that become dilated
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| ventricular gallop | Abnormal low-pitched extra heart sound (S3) heard in early diastole.
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| vocal fremitus | Vibrations created by sound waves that can be palpated externally.
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| whispered pectoriloquy | Transmission of a whisper through the pulmonary structures so that it is heard as normal audible speech on auscultation.
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| aphasia | Loss of ability to comprehend language or communicate
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| benign breast disease (fibrocystic) | "Condition characterized by lumpy
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| capillary refill | The time it takes for a nail bed to return to its usual color after the blood flow has been momentarily occluded—is an indicator of peripheral circulation.
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| squamous cell carcinoma | Skin cancer that develops on outer layers of sun damaged skin; may travel to lymph nodes.
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| client-centered problems | What nursing leaders and educators revised their curricula to reflect.
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| outcome | Condition to be achieved as a result of health care delivery. Favorable or adverse changes in clients' health states due to prior or concurrent care.
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| acupressure | "Therapeutic technique of applying digital pressure in a specified way on designated points on the body to relieve pain
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| acute pain | "Follows acute injury
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| addiction | "A primary
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| breakthrough pain | Pain that extends beyond treated steady chronic pain.
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| chronic pain | "Pain that lasts longer than anticipated (usually over 6 months)
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| cutaneous stimulation | "Stimulation of a person's skin to prevent or reduce pain perception. A massage
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| drug tolerance | A state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time.
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| epidural space | Where the epidural analgesia is administered.
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| guided imagery | "Method of pain control in which the client creates a mental image
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| idiopathic pain | Pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of organic pathological condition.
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| modulation | Alteration in the magnitude or any variation in the duration of an electrical current.
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| nociceptor | Somatic and visceral free nerve endings of thinly myelinated and unmyelinated fibers; these fibers usually react to tissue injury but may also be excited by endogenous chemical substances.
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| nutrients | "Foods that contain elements necessary for body function
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| opioid | Pertaining to natural and synthetic chemicals that have opium-like effects although they are not derived from opium.
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| pain | """An unpleasant
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| pain threshold | The point at which a person feels pain.
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| pain tolerance | The level of pain that a person is willing to put up with.
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| patient-controlled analgesia (PCA) | Drug delivery system that allows clients to self-administer analgesic medications as desired.
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| physical dependence | "A state of adaptation that is manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation
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| placebo | Inert substance with no active ingredient.
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| prostaglandins | Potent hormonelike substances that act in exceedingly low doses on target organs; they can be used to treat asthma and gastric hyperacidity.
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| pruritus | Symptom of itching.
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| pseudoaddiction | Patient behaviors (drug seeking) that may occur when pain is undertreated.
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| pseudotolerance | "The need to increase opioid dose for reasons other than opioid tolerance: progression of disease
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| standard of care | Minimum level of care accepted to ensure high quality of care to clients. Standards of care define the types of therapies typically administered to clients with defined problems or needs.
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| transcutaneous electrical nerve stimulation (TENS) | Technique in which a battery-powered device blocks pain impulses from reaching the spinal cord by delivering weak electrical pulses directly to the skin's surface.
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| transduction | Process that begins in the periphery when a pain-producing stimulus sends an impulse across a peripheral nerve fiber.
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| transmission | Transfer or conveyance of a thing or condition.
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| analgesics | Medications that provide pain relief
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| epidural anesthesia | Pain management via the epidural space
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| perineural infusion | An unsutured catheter from a surgical wound placed near a nerve or groups of nerves connects to a pump containing a local anesthetic
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| consultations | Process in which the help of a specialist is sought to identify ways to handle problems in client management or in the planning and implementation of programs.
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| critical pathway | "Tool used in managed care that incorporates the treatment interventions of caregivers from all disciplines who normally care for a client. Designed for a specific case type
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| Kardex | Trade name for card-filing system that allows for quick reference to the particular need of the client for certain aspects of nursing care.
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| quality improvement | Monitoring and evaluation of processes and outcomes in health care or any other business to identify opportunities for improvement.
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| case management | "Model of care; the case manager advises nursing staff on specific nursing care issues
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| incident reports | "Tools used in risk management to report an accident or a deviation from policies or prescribed orders involving clients
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| activities of daily living (ADLs) | "Activities usually performed in the course of a normal day in the client's life
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| pulse deficit | Condition that exists when the radial pulse is less than the ventricular rate as auscultated at the apex or seen on an electrocardiogram; indicates a lack of peripheral perfusion for some of the heart contractions.
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| instrumental activities of daily living (IADLs) | "Activities that are required for an individual to be independent in society beyond eating
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| perception | "Person's mental image or concept of elements in the environment
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| alopecia | Partial or complete loss of hair; baldness.
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| caries | "Abnormal condition of a tooth
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| cerumen | "A yellow
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| local anesthesia | Loss of sensation at the desired site of action.
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| cyanosis | Bluish discoloration of the skin and mucous membranes caused by deoxygenated hemoglobin in the blood or a structural defect in hemoglobin.
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| orthopnea | Abnormal respiratory symptom in which a person must sit or stand to breathe deeply or comfortably.
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| phlebitis | Inflammation of a vein.
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| excoriation | Injury to the skin's surface caused by abrasion.
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| hemorrhoid | Permanent dilation and engorgement of a vein within the lining of the rectum.
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| polyps | Small tumorlike growths that projects from a mucous membrane surface.
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| relaxation | Relief from work or stress that leaves one feeling relaxed or less tense.
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| biofeedback | Behavioral therapy that involves giving individuals information about physiological responses (such as blood pressure or tension) and ways to exercise voluntary control over those responses.
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| osteoporosis | "Disorder characterized by abnormal rarefaction of bone
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| neurotransmitter | Chemical that transfers an electrical impulse from the nerve fiber to the muscle fiber.
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| regional anesthesia | Loss of sensation in an area of the body supplied by sensory nerve pathways.
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| dysrhythmia | Heartbeat that deviates from the normal pattern.
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| edema | Abnormal accumulation of fluid in interstitial spaces of tissues.
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| peristalsis | "Coordinated
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| 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.
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