The five-step nursing process: Assessment, Diagnosis, Planning, Implementation, Evaluation. A systematic framework for providing patient-centered nursing care.
A physical assessment term meaning the head is normal in size, shape, and appearance. Used in head-to-toe assessment documentation.
No signs of trauma or injury. In physical assessment, 'normocephalic and atraumatic' indicates a normal head without injury signs.
NANDA International: the organization that develops and maintains the standardized nursing diagnosis taxonomy used worldwide.
Nursing Interventions Classification: a comprehensive taxonomy of evidence-based nursing interventions organized by nursing diagnoses.
Nursing Outcomes Classification: a standardized classification of patient outcomes used to evaluate nursing interventions.
Pain assessment mnemonic: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity.
A structured clinical documentation format: Subjective (patient's report), Objective (measurable data), Assessment (clinical interpretation), Plan (action plan).
Structured communication framework: Situation, Background, Assessment, Recommendation. Used for handoff communication between healthcare providers.
Framework for formulating clinical research questions: Population, Intervention, Comparison, Outcome, Time.
The integration of best research evidence, clinical expertise, and patient values to make clinical decisions and improve patient outcomes.
Pupils Equal, Round, Reactive to Light and Accommodation. A normal finding in the eye assessment portion of a physical exam.
Extraocular Movements Intact. Indicates all six cardinal positions of gaze are functioning normally during eye assessment.
Diabetic Ketoacidosis: a life-threatening complication of diabetes (primarily Type 1) characterized by hyperglycemia, ketosis, and metabolic acidosis.
Hyperosmolar Hyperglycemic State: a serious complication of Type 2 diabetes with severe hyperglycemia (>600 mg/dL), dehydration, and altered mental status without significant ketosis.
Arterial Blood Gases: a lab test measuring pH, PaCO2, HCO3, and PaO2 to assess acid-base balance and oxygenation.
Brain Natriuretic Peptide: a biomarker released by ventricles in response to increased wall stress. Elevated levels indicate heart failure.
Glycated hemoglobin: reflects average blood glucose over the past 2-3 months. Normal <5.7%, diabetic ≥6.5%, goal <7% for most diabetics.
A validated tool for assessing pressure injury risk. Evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Score ≤18 indicates risk.
A neurological assessment tool scoring eye opening (1-4), verbal response (1-5), and motor response (1-6). Total score range: 3-15. Score ≤8 indicates severe brain injury.
A framework for prioritizing patient needs: Physiological (first priority), Safety, Love/Belonging, Esteem, Self-Actualization. Used in nursing prioritization and care planning.
A clinical sign of hypocalcemia: carpal spasm (hand contraction) occurring when a blood pressure cuff is inflated on the upper arm for 3 minutes.
A clinical sign of hypocalcemia: facial muscle twitching when the facial nerve is tapped anterior to the ear.
A behavioral pain assessment scale for children (2 months - 7 years) who cannot self-report. Measures Face, Legs, Activity, Cry, Consolability. Score range: 0-10.
Newborn assessment at 1 and 5 minutes after birth: Appearance, Pulse, Grimace, Activity, Respirations. Score range: 0-10. Score 7-10 is normal.
Deep, rapid breathing pattern seen in metabolic acidosis (especially DKA). The body's attempt to compensate by blowing off CO2.
Difficulty breathing when lying flat, relieved by sitting upright. Common in heart failure due to pulmonary congestion. Documented as number of pillows needed (e.g., '3-pillow orthopnea').
The transfer of responsibility for performing a nursing activity to another qualified person while retaining accountability for the outcome. Governed by the Five Rights of Delegation.
The patient's voluntary agreement to a proposed treatment or procedure after receiving adequate information about risks, benefits, and alternatives. The nurse's role is to witness, not obtain, consent.
Health Insurance Portability and Accountability Act: federal law protecting patient health information privacy and security. Violations can result in civil and criminal penalties.
Quick Sequential Organ Failure Assessment. A bedside screening tool for sepsis risk using three criteria: respiratory rate ≥22, altered mentation (GCS <15), and systolic BP ≤100 mmHg. Score ≥2 indicates high risk.
A life-threatening organ dysfunction caused by a dysregulated host response to infection. Defined by Sepsis-3 criteria as suspected infection plus acute increase of ≥2 SOFA points.
Commonly called a stroke. Occurs when blood flow to part of the brain is interrupted by a clot (ischemic, 87%) or vessel rupture (hemorrhagic, 13%), causing brain cell death.
Serum potassium level above 5.0 mEq/L. Causes include renal failure, ACE inhibitors, acidosis, and tissue trauma. ECG shows tall peaked T waves, widened QRS. Can lead to cardiac arrest.
Serum potassium level below 3.5 mEq/L. Common causes include loop diuretics, vomiting, and diarrhea. ECG shows flattened T waves and prominent U waves. Increases digoxin toxicity risk.
Leakage of non-vesicant IV fluid or medication into surrounding tissue due to catheter dislodgement from the vein. Signs include swelling, coolness, pallor at site, and decreased flow rate.
Inflammation of a vein, commonly caused by IV catheter irritation (mechanical), irritating solutions (chemical), or bacteria (infectious). Signs include redness, warmth, tenderness, and a red streak along the vein.
Difficulty swallowing, common after stroke due to cranial nerve dysfunction. Requires swallowing assessment before oral intake. Risk factor for aspiration pneumonia.
Abnormally rapid respiratory rate, generally defined as >20 breaths per minute in adults. Can indicate respiratory distress, sepsis, metabolic acidosis, pain, or anxiety.
Heart rate below 60 beats per minute. May be normal in athletes or during sleep. Pathological causes include beta-blockers, hyperkalemia, increased ICP, hypothyroidism, and inferior MI.