CPNRE / REx-PN key terms

The set of activities a nurse is legally permitted and competent to perform, set by provincial or territorial legislation, regulatory college standards, and employer policy. It defines when a task must be delegated, supervised, or refused.

Transferring the authority to perform a specific task to another person while the delegating nurse keeps responsibility for the decision to delegate and for the overall outcome. The delegate must be competent and the task must be within legal limits.

A worker such as a personal support worker or health care aide who assists with personal care but holds no nursing licence. The registered nurse remains accountable for assessing the client, planning care, and deciding which tasks may safely be assigned.

Being answerable for one's own nursing judgments, actions, and omissions, including the duty to report errors, near misses, and unsafe conditions. Accountability cannot be delegated to a colleague, manager, or physician.

Acting to protect and promote a client's rights, choices, and access to care, including speaking up when the client cannot do so. It includes supporting informed decisions even when they differ from the nurse's personal values.

A client's voluntary agreement to a treatment or procedure after receiving and understanding the purpose, risks, benefits, alternatives, and consequences of refusing. The nurse confirms capacity and understanding and witnesses the signature; the person performing the procedure obtains consent.

A client's ability to understand relevant information and appreciate the reasonably foreseeable consequences of a decision at the moment it is made. Capacity is decision-specific, can fluctuate, and is assessed clinically rather than assumed from a diagnosis.

A written or recorded statement of a person's values and wishes about future health care, made while capable, to guide decisions if they later lose capacity. It may name a substitute decision-maker and is used alongside, not instead of, current clinical assessment.

The defined sequence of people to notify when a clinical concern is not resolved at the bedside, moving from the most responsible nurse to the charge nurse, manager, and physician or administrator. Following it promptly is a professional obligation when client safety is at risk.

A factual, objective record of an unexpected event such as a fall, medication error, or injury, completed to support follow-up and system improvement. It is filed separately from the health record, is not mentioned in the chart, and is not a substitute for documenting the client's condition.

Planning and delivering care around the client's own goals, preferences, culture, and circumstances, with the client as a partner in decisions. It includes respecting autonomy, offering choice, and involving family as the client wishes.

Cleaning hands with alcohol-based rub or soap and water at the four moments of patient contact: before touching a client, before a clean procedure, after body fluid exposure risk, and after touching a client or their surroundings. It is the single most effective way to prevent health care-associated infection.

Precautions applied to every client regardless of diagnosis, because infection status is often unknown. They include hand hygiene, gloves when contact with blood or body fluids is anticipated, gowns, masks and eye protection for splash risk, and safe handling of sharps and waste.

Extra measures beyond routine practices, used when a specific pathogen requires them. Contact precautions add gown and gloves and often a private room; droplet precautions add a surgical mask within about two metres; airborne precautions add a fit-tested N95 respirator and a negative-pressure room.

Barrier items such as gloves, gowns, masks, respirators, and eye protection worn to prevent exposure to infectious agents or hazardous substances. Selection depends on the anticipated exposure, and equipment must be removed in the correct order to avoid self-contamination.

An infection a client acquires while receiving care that was not present or incubating at admission. Common types include urinary catheter-associated infection, surgical site infection, bloodstream infection from central lines, and ventilator-associated pneumonia, many of which are preventable with device care bundles.

Practices that keep an area or object free of microorganisms. Medical asepsis reduces the number and spread of organisms in everyday care; surgical asepsis keeps sterile fields and items free of all organisms during procedures such as catheter insertion or dressing changes.

Any physical, mechanical, or chemical means of limiting a client's freedom of movement or behaviour that is used as a last resort, only when less restrictive measures have failed and there is imminent risk of harm. It requires a physician or nurse practitioner order, time limits, monitoring, and frequent reassessment.

The likelihood that a client will fall, increased by factors such as age, medications, delirium, impaired mobility, incontinence, and unfamiliar surroundings. Prevention includes orientation, call bell access, non-slip footwear, bed brakes, clutter removal, and individualized toileting rounds.

A structured list used before, during, or after a task to confirm critical steps have been completed, such as surgical safety checks or central line insertion bundles. It standardizes practice and reduces omissions, but does not replace clinical judgment.

Actions that help people increase control over and improve their health, going beyond treating illness. Examples include immunization, screening, physical activity counselling, healthy eating support, and creating supportive environments and policies.

Testing apparently healthy people to find disease or risk factors early, when treatment is more effective. Screening programs require a suitable test, defined population, agreed follow-up, and evidence that early detection improves outcomes.

Planned teaching that gives clients the knowledge and skills to manage their health, tailored to their literacy, culture, readiness, and preferred learning style. Effectiveness is confirmed by teach-back or return demonstration, not by the nurse's delivery of information.

A method of confirming understanding by asking the client to explain or demonstrate the information in their own words. It shifts responsibility for clear communication to the nurse and reveals gaps without making the client feel tested.

A person's ability to find, understand, and use health information to make decisions. Low health literacy is common and is addressed with plain language, pictures, limited key messages, and checking understanding rather than assuming it.

A collaborative, goal-oriented conversation style that helps a client explore and resolve ambivalence about change. It uses open questions, affirmation, reflective listening, and summarizing, and avoids arguing, lecturing, or giving unsolicited advice.

A professional, goal-directed connection between nurse and client built on trust, respect, empathy, and clear boundaries. It is time-limited and focused on the client's needs, and differs from a friendship or social relationship.

Purposeful verbal and nonverbal techniques, such as open-ended questions, restating, reflecting, silence, and offering information, that help clients express feelings and clarify concerns. It avoids false reassurance, advice-giving, and changing the subject.

Fully attending to a client's words, tone, and body language, then reflecting back what was understood to confirm accuracy. It communicates respect, encourages the client to continue, and reduces misunderstandings.

An acute, fluctuating disturbance of attention and awareness, often caused by infection, medications, pain, withdrawal, or metabolic imbalance. It develops over hours to days, worsens at night, and is a medical emergency that requires finding and treating the cause.

A chronic, progressive decline in cognition, such as memory and language, that interferes with daily function and is not explained by delirium. Care focuses on safety, routines, orientation, meaningful activity, and supporting caregivers.

A person's emotional, physical, and social response to loss, which may be anticipatory, acute, or prolonged. Responses vary widely across cultures and individuals, and nurses support expression and mourning rather than judging the expected timeline.

Systematically gathering the client's self-report of pain, its location, quality, intensity, timing, and effect on function, plus observable signs when self-report is limited. Reassessment after intervention is required to judge effectiveness.

An intervention that relieves distress without drugs, such as repositioning, warmth or cooling, oral care, back rub, music, distraction, or relaxation breathing. These measures complement analgesia, reduce the dose needed, and are used before or alongside medication.

Habits and environmental conditions that support restful sleep, including a consistent schedule, limited caffeine and screens before bed, darkness and quiet, and daytime activity. In hospital, it means clustering care and reducing night-time interruptions.

Localized damage to skin and underlying tissue, usually over a bony prominence, from sustained pressure or pressure combined with shear and moisture. Prevention includes risk assessment, repositioning, support surfaces, skin care, and adequate nutrition and hydration.

A scored risk assessment for pressure injury based on sensory perception, moisture, activity, mobility, nutrition, and friction or shear. Lower scores mean higher risk and guide the frequency of repositioning and the choice of support surface.

Any preventable event that may cause or lead to inappropriate medication use or client harm, such as a wrong drug, dose, route, time, or client. The nurse stops and assesses the client, reports promptly, monitors for effects, and documents factually.

The checks performed before giving any drug: right client using two identifiers, right medication, dose, route, time, and documentation, plus the client's right to refuse and to be informed. These checks are done at the point of administration, not only when preparing.

A drug that carries a heightened risk of significant harm when used in error, such as insulin, heparin, opioids, and concentrated electrolytes. Safeguards include independent double checks, standardized concentrations, limited access, and clear labelling.

The blood concentration range in which a drug is expected to be effective with acceptable toxicity, used for drugs with narrow margins such as digoxin, lithium, and vancomycin. Timing of the sample relative to the dose is critical, and levels guide dose adjustment.

An unintended, harmful response to a drug given at a normal dose, ranging from rash to anaphylaxis. The nurse recognizes the signs, stops the drug as ordered, supports the airway and circulation, and reports the reaction.

The volume of fluid delivered per unit time, calculated from the ordered volume and duration and set with a pump or by counting drops per minute using the tubing's drop factor. It is checked against the order and reassessed with the client's response.

Leakage of intravenous fluid into surrounding tissue, causing swelling and coolness; extravasation involves a vesicant drug and can cause tissue necrosis. The infusion is stopped, the cannula is assessed, and the prescribed antidote or cold or warm compress is applied.

Excess fluid in the body from too-rapid or excessive intravenous or oral intake or impaired elimination, shown by weight gain, edema, crackles, dyspnea, and raised jugular venous pressure. The rate is slowed as ordered, the client is positioned upright, and oxygen and diuretics may be needed.

A severe, rapidly developing, potentially fatal allergic reaction with airway swelling, bronchospasm, hypotension, and urticaria. The priority is to stop the trigger, call for help, maintain the airway, and give epinephrine as ordered while supporting circulation.

A tool that combines vital signs such as respiratory rate, oxygen saturation, blood pressure, heart rate, temperature, and consciousness into a score that flags deterioration. A rising score triggers escalation through the chain of command before a crisis occurs.

The percentage of hemoglobin carrying oxygen, estimated non-invasively by pulse oximetry. Readings are affected by poor perfusion, nail polish, motion, and anemia, so they are interpreted with the client's clinical picture rather than alone.

Life-threatening organ dysfunction caused by a dysregulated response to infection, suggested by fever or low temperature, tachycardia, tachypnea, altered mentation, and hypotension. Early recognition, cultures, antibiotics, and fluid resuscitation improve survival.

Blood glucose below the client's target, commonly under 4.0 mmol/L, causing sweating, tremor, hunger, confusion, and possibly seizures or coma. A conscious client is given fast-acting oral carbohydrate and retested; an unconscious client needs intravenous glucose or glucagon.

A drop in blood pressure on moving from lying to sitting or standing, often defined as a fall of at least 20 mmHg systolic or 10 mmHg diastolic, with dizziness or syncope. It is linked to dehydration, prolonged bed rest, and some medications, and is managed by rising slowly and hydrating.

A quick first-line check of weight change, appetite, intake, and disease burden to identify clients who need a fuller nutrition assessment. It triggers referral and support such as feeding assistance, supplements, and dietitian involvement.