GPNC(C) key terms

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives, given by someone with decision-making capacity or a legally authorized representative.

A written statement prepared while a patient is capable, naming a surrogate decision-maker or specifying preferred treatments, so wishes are known if the patient later loses capacity.

A clinician-assessed ability to understand relevant information, appreciate consequences, reason through options, and communicate a consistent choice; it is task-specific and distinct from legal competence.

A legal duty for nurses to notify designated authorities of specified events such as suspected child or elder abuse, certain communicable diseases, or serious injuries, regardless of patient preference.

The obligation to breach confidentiality when a patient poses a credible serious threat to an identifiable person, notifying the intended victim and authorities as permitted by law.

A safety framework that treats human error without blame, consoles the clinician, and still holds individuals accountable for reckless behavior, encouraging honest reporting of mistakes.

A structured team review after a serious event that maps the sequence of decisions and system conditions contributing to harm, then identifies corrective actions rather than blaming one person.

An unexpected occurrence involving death, permanent harm, or severe temporary harm that signals a need for immediate investigation and system-level response.

A proactive team method that breaks a planned process into steps, predicts how each step could fail, and ranks failures by severity and likelihood before harm occurs.

A small, rapid test-of-change method in which a team plans an improvement, runs it, studies the results, and acts on what was learned before scaling further.

A measurable marker, such as falls per 1,000 patient days or catheter-associated infection rates, used to track care performance and compare it against benchmarks over time.

An environment in which any team member, regardless of rank, can raise safety concerns and stop an unsafe action without fear of retaliation.

A structured handoff format covering Situation, Background, Assessment, and Recommendation, used to convey clinical concerns concisely and reduce omissions during transfers of care.

Purposeful verbal and nonverbal interaction using open questions, reflection, silence, and empathy to help a patient express feelings and make informed choices, without giving false reassurance.

Attending fully to a patient's words and feelings, using eye contact, nods, paraphrasing, and clarifying questions to confirm understanding rather than rehearsing a reply.

A deliberately structured inpatient environment with predictable routines, clear behavioral expectations, and safe interpersonal boundaries that supports recovery and reduces escalation.

A graduated verbal and environmental approach to an agitated person using calm tone, reduced stimulation, personal space, and offered choices to lower risk before any physical intervention.

Any physical device or medication that restricts freedom of movement and is used only for immediate safety, with a time-limited order, monitoring, and frequent reassessment.

An acute, fluctuating disturbance of attention and awareness, often triggered by infection, medication, pain, or withdrawal, that is distinct from a gradual dementia course.

A chronic, progressive decline in cognition affecting memory and daily function, usually irreversible, in which abrupt worsening should prompt a search for a superimposed delirium.

A structured assessment of appearance, behavior, speech, mood, thought content, perception, cognition, insight, and judgment, documenting a baseline for later comparison.

A targeted examination of one body system or complaint, guided by the patient's history and presenting problem, to confirm or rule out likely causes quickly.

A prioritized survey of Airway, Breathing, Circulation, Disability, and Exposure, repeated after each intervention to detect deterioration in a seriously ill patient.

A hospital team that can be summoned by any staff member when a patient shows early warning signs such as falling oxygen saturation or altered consciousness, before cardiac arrest occurs.

A numeric score combining vital signs such as respiratory rate, oxygen saturation, blood pressure, pulse, temperature, and consciousness to flag patients at risk of deterioration.

Inadequate tissue perfusion from causes such as hemorrhage, sepsis, or pump failure, showing as low blood pressure, cool or mottled skin, altered mentation, and reduced urine output.

Life-threatening organ dysfunction caused by a dysregulated response to infection, identified by signs such as altered mentation, low blood pressure, and rising lactate.

The average pressure driving blood into tissues across the cardiac cycle, estimated as one-third of pulse pressure plus diastolic pressure, with roughly 65 mm Hg needed for organ perfusion.

A drug with heightened risk of serious harm when used in error, such as insulin, heparin, opioids, and concentrated electrolytes, requiring independent double checks and standardized labeling.

The verified conditions checked before giving any drug, including the right patient, drug, dose, route, time, and documentation, plus the patient's right to refuse.

The ratio between a drug's toxic dose and its effective dose; a narrow index means small dose changes can cause toxicity, so serum levels and signs are monitored closely.

A harmful, unintended response to a medication at normal doses, ranging from rash to anaphylaxis, which must be documented, reported, and distinguished from a medication error.

A severe, rapid allergic reaction with airway swelling, bronchospasm, and falling blood pressure, treated immediately with intramuscular epinephrine plus oxygen and fluids.

A pump system letting a patient self-administer small preset opioid doses within lockout limits, improving pain control while requiring monitoring for sedation and respiratory depression.

A slowing of breathing rate and depth from opioid effect, signaled by sedation, reduced respiratory rate, and falling oxygen saturation, managed by stopping the opioid and giving naloxone.

The comparison of all intake, including oral, intravenous, and irrigation, against all output, including urine, drainage, and insensible loss, recorded over a defined period.

A syndrome in which the heart cannot pump enough blood for the body's needs, producing dyspnea, fatigue, edema, and weight gain from fluid retention.

A sudden drop in kidney function over hours to days, shown by rising creatinine and falling urine output, often caused by dehydration, nephrotoxic drugs, or obstruction.

The likelihood a patient will fall, increased by sedatives, orthostatic hypotension, footwear, unfamiliar surroundings, and history, addressed with bed alarms, lighting, and assistance.

A small set of evidence-based practices, such as hand hygiene, sterile barriers, and daily review, performed together to reliably prevent a specific complication.

Cleaning hands with alcohol rub or soap and water at defined moments, including before patient contact and after body fluid exposure, to interrupt organism transmission.

Routine infection-control practices applied to every patient, including hand hygiene, gloves, gowns, masks, and safe sharps handling, based on anticipated exposure to blood or body fluids.

Extra measures layered onto standard precautions for specific organisms, using contact, droplet, or airborne routes with appropriate barriers, room placement, and patient transport limits.

A bloodstream infection attributed to a central venous catheter, prevented by sterile insertion, chlorhexidine skin antisepsis, daily necessity review, and prompt removal.

Excessive blood loss after birth, commonly from uterine atony, signaled by heavy bleeding, a soft boggy uterus, and rising heart rate, managed with uterine massage and uterotonics.

A pregnancy disorder of new high blood pressure with proteinuria or organ dysfunction after 20 weeks, risking seizures and placental problems, treated with magnesium and delivery planning.

Continuous or intermittent recording of fetal heart rate with uterine activity to identify oxygen deprivation, interpreted by baseline rate, variability, accelerations, and decelerations.

The first hours after birth when the infant clears lung fluid, establishes breathing, and adjusts circulation, assessed by heart rate, respiratory effort, tone, reflexes, and color.

Calculating a child's medication dose from body weight in kilograms, verifying safe ranges, and using oral syringes or buretrols because small volume errors cause large relative harm.