Nursing process: Assess, diagnose, plan, implement, evaluate ADPIE: Memory aid for the five steps of the nursing process Assessment: Gathering information about the patient Subjective data: What the patient reports (symptoms) Objective data: What the nurse observes or measures (signs) Nursing diagnosis: A clinical judgment about a patient's response to a health problem Care plan: Written plan of goals and nursing actions Evaluation: Judging whether goals were met Vital signs: Temperature, pulse, respiration, blood pressure, and often oxygen saturation Normal adult pulse: About 60 to 100 beats per minute Normal adult respirations: About 12 to 20 breaths per minute Normal adult temperature: About 98.6 F (37 C), with some natural variation Normal blood pressure: About 120/80 mmHg or lower Bradycardia: Slow heart rate Tachycardia: Fast heart rate Hypotension: Low blood pressure Hypertension: High blood pressure Hypoxia: Low oxygen in body tissues Dyspnea: Difficulty breathing Apnea: Pause in breathing Pulse oximeter: Device that measures oxygen saturation Hand hygiene: The most important way to prevent infection Standard precautions: Basic infection control used for every patient Contact precautions: Gloves and gowns to prevent spread by touch Droplet precautions: Mask for germs spread by large respiratory droplets Airborne precautions: Special room and respirator for germs that travel on air PPE: Personal protective equipment such as gloves, gown, mask and goggles Aseptic technique: Methods to prevent contamination by germs Sterile field: Area kept free of all microorganisms Fomite: An object that can carry infection Nosocomial infection: Infection acquired in a healthcare setting Six rights of medication: Right patient, drug, dose, route, time and documentation Medication reconciliation: Comparing a patient's medication lists to avoid errors Allergy: Overreaction of the immune system to a substance Anaphylaxis: Severe, life-threatening allergic reaction Informed consent: A patient agrees to treatment after understanding it HIPAA: US law protecting patients' health information Confidentiality: Keeping patient information private Advance directive: Written wishes about future medical care Patient advocate: Someone who speaks up for a patient's rights and needs Scope of practice: What a licensed professional is legally allowed to do Delegation: Assigning a task to someone else while keeping accountability Chain of command: Order of reporting concerns SBAR: Situation, Background, Assessment, Recommendation: a communication format Therapeutic communication: Communication that helps and supports patients Active listening: Fully focusing on and responding to what is said Documentation: Writing accurate records of care Charting by exception: Recording only findings that differ from normal Maslow's hierarchy: Basic needs come before higher needs Activities of daily living: Everyday self-care tasks like bathing and eating Fall risk: Likelihood that a patient will fall Pressure injury: Skin damage from prolonged pressure Turning schedule: Repositioning to prevent pressure injuries Ambulation: Walking Body mechanics: Using the body safely when lifting and moving Range of motion: The full movement a joint can make Intake and output: Measuring fluids a patient takes in and puts out Dehydration: Not enough water in the body Edema: Swelling from excess fluid in tissue Isotonic IV fluid: Fluid with the same concentration as blood plasma Catheter: A tube inserted into the body to drain or deliver fluid Enteral nutrition: Feeding through the digestive tract, such as a tube Parenteral nutrition: Nutrients given directly into the bloodstream NPO: Nothing by mouth Aspiration: Food or fluid entering the airway Wound healing: Stages: hemostasis, inflammation, proliferation and remodeling Dressing: Material that covers and protects a wound Pain scale: Tool for patients to rate pain, such as 0 to 10 Palliative care: Care focused on comfort and quality of life Hospice: End-of-life care focusing on comfort Triage: Sorting patients by urgency of need Rapid response: Team called when a patient is getting worse quickly Code blue: Hospital emergency call for cardiac or respiratory arrest Restraint: A device limiting movement, used only as a last resort Cultural competence: Respecting and meeting patients' cultural needs Health literacy: Ability to understand health information Teach-back: Asking patients to explain instructions in their own words Primary prevention: Stopping disease before it starts, like vaccination Secondary prevention: Early detection, like screening Tertiary prevention: Reducing the effects of existing disease Evidence-based practice: Using the best research along with clinical judgment Chain of infection: Agent, reservoir, exit, transmission, entry, host Sharps container: Rigid, puncture-proof box for needles Incident report: Record of an unusual event, such as a fall or error Near miss: An error caught before it reaches the patient Bedsore stages: Stages 1 to 4 describing the depth of pressure injury Orthostatic hypotension: Blood pressure drop when standing up Free flashcards from Peabody at peabody.kids/flashcards/tp-nursing-basics