ANCC MedSurg-BC key terms

A targeted history and physical examination limited to the patient's presenting problem or affected body system, used to detect changes and guide immediate clinical decisions.

The cognitive process of synthesizing assessment data, recognizing patterns, generating and testing explanations, and selecting the most likely cause to guide nursing and medical actions.

The observed outcome of critical thinking in which a nurse interprets patient data, identifies concerns, and chooses an appropriate response within the clinical context.

Regulation of blood pH through chemical buffers, respiratory carbon dioxide elimination, and renal bicarbonate handling; evaluated with arterial blood gas values and the anion gap.

Systematic analysis of pH, PaCO2, PaO2, bicarbonate, and oxygen saturation to identify respiratory or metabolic acidosis or alkalosis and determine whether compensation is present.

A primary acid-base disorder with low pH and low bicarbonate, often caused by ketosis, lactic acidosis, renal failure, or diarrhea; assessed with the anion gap and compensation status.

Decreased intravascular or extracellular fluid marked by thirst, tachycardia, orthostatic hypotension, low urine output, and poor skin turgor, requiring careful replacement and monitoring.

Expansion of extracellular fluid from increased intake or impaired excretion, producing edema, weight gain, crackles, jugular venous distention, and hypertension; managed with diuretics, sodium restriction, and monitoring.

Elevated serum potassium, often from renal impairment, medications, or tissue breakdown, that can cause peaked T waves, muscle weakness, and life-threatening arrhythmias requiring urgent treatment.

Systematic evaluation of pain using the patient's self-report, validated scales appropriate to age and cognition, and assessment of location, quality, intensity, timing, and functional impact.

An acute, fluctuating disturbance of attention and awareness often triggered by illness, surgery, medications, or withdrawal; distinguished from dementia by its rapid onset and reversibility.

A structured evaluation of factors such as mobility, medications, cognition, continence, and prior falls to identify patients who need fall-prevention interventions.

Life-threatening organ dysfunction caused by a dysregulated response to infection, identified by signs such as fever, tachycardia, hypotension, altered mentation, and elevated lactate.

Sepsis with persistent hypotension requiring vasopressors and elevated lactate despite adequate fluid resuscitation, carrying high mortality and needing urgent critical care.

A laboratory value reflecting tissue hypoperfusion and anaerobic metabolism; rising or persistently elevated levels in sepsis signal inadequate resuscitation and increased risk.

B-type natriuretic peptide, a hormone released by stretched ventricles; elevated levels support the diagnosis of heart failure and can help track response to treatment.

Noninvasive estimation of arterial oxygen saturation using light absorption; readings may be unreliable with poor perfusion, nail polish, or motion, so clinical correlation is required.

Blood glucose below the patient's target or typically under 70 mg/dL, causing shakiness, sweating, confusion, and seizures; treated promptly with fast-acting carbohydrate or glucagon.

Measuring capillary or interstitial glucose to guide insulin dosing, detect hypo- and hyperglycemia, and evaluate the response to nutrition and medication.

A hormone medication used to lower blood glucose; regimens vary by onset and duration, and administration requires matching to meals, activity, and glucose monitoring while preventing hypoglycemia.

Interventions such as anticoagulants, compression devices, and early ambulation used to prevent deep vein thrombosis in at-risk patients, especially after surgery or during immobility.

Practices that reduce bleeding risk with heparin, warfarin, or direct oral anticoagulants, including correct dosing, laboratory monitoring, fall precautions, and patient education about bleeding signs.

Assessment and management of wounds using appropriate cleansing, debridement, dressing selection, and moisture balance to promote healing and prevent infection.

Practices that prevent contamination of sterile sites or devices by using sterile supplies, proper hand hygiene, and maintaining sterile fields during invasive procedures.

A planned teaching process that gives patients and families the knowledge and skills needed for self-management, informed decisions, and safe transitions, tailored to health literacy and readiness.

A collaborative process beginning at admission that identifies needs, arranges resources, and coordinates follow-up to ensure a safe transition from hospital to home or another setting.

Systematic comparison of a patient's current status with expected goals and benchmarks to determine whether interventions are effective and whether the plan needs revision.

Repeat focused data collection after an intervention or change in condition to detect improvement, deterioration, or new problems and to guide timely adjustments in care.

A method of confirming understanding by asking the patient to explain or demonstrate information in their own words; misunderstanding triggers reteaching rather than simple repetition.

A measurable standard such as fall rate, pressure injury incidence, or readmission rate used to monitor and compare the quality of nursing and organizational care.

Transferring the performance of a task to another team member while the delegating nurse retains accountability for appropriate assignment, supervision, and evaluation of the outcome.

The legally defined activities and responsibilities a licensed nurse may perform based on education, licensure, and state regulation, often described by state nurse practice acts.

Acting to protect and promote a patient's rights, preferences, and safety, including speaking up about concerns and ensuring informed decision-making.

The process by which a patient voluntarily agrees to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives; the provider obtains consent.

Clinical decision-making that integrates the best available research evidence, clinician expertise, and patient values and preferences to improve care quality.

The transfer of patient information and accountability between caregivers, ideally using a standardized format and including an opportunity for questions, to preserve safety across transitions.

A structured communication format-Situation, Background, Assessment, Recommendation-used to convey concise, complete patient information during handoffs or when escalating concerns.