HS 323 key terms

The range of duties, tasks, and decision-making a health worker is legally and professionally permitted to perform, set by law, licensure, employer policy, and demonstrated competence.

The level and type of care a reasonably prudent practitioner with similar training would provide in comparable circumstances; it is the benchmark used to judge whether care was appropriate.

Transferring authority to another person to perform a specific task while the delegating professional keeps accountability for deciding what may be delegated and for the outcome.

Clinical decision-making that combines the best available research evidence, the clinician's expertise, and the patient's values and preferences rather than relying on habit or tradition alone.

Systematically developed statements that recommend how to assess and manage specific clinical conditions, based on a review of evidence and intended to reduce unwarranted variation in care.

The body's active maintenance of internal conditions such as temperature, pH, glucose, and fluid balance within narrow ranges despite changes in the external environment.

A control mechanism in which a change in a body variable triggers a response that reverses the change, returning the variable toward its set point; most physiological regulation works this way.

Physiological adjustment by which the body offsets a dysfunction to keep critical functions within workable limits, such as increased respiratory rate to correct metabolic acidosis.

The flow of blood through tissue capillaries delivering oxygen and nutrients and removing wastes; inadequate perfusion causes cellular hypoxia and, if prolonged, organ dysfunction.

A life-threatening state in which tissue perfusion is inadequate to meet cellular oxygen demand, producing altered mentation, low or falling blood pressure, and signs of organ hypoperfusion.

The body's local vascular and cellular response to injury or infection, classically producing redness, heat, swelling, pain, and sometimes loss of function.

A microorganism such as a bacterium, virus, fungus, or parasite that can cause disease in a host; not all microorganisms are pathogenic.

The invasion and multiplication of a pathogen in body tissue that may or may not produce symptoms; clinical infection usually involves tissue damage and an immune response.

Regulation of hydrogen ion concentration in body fluids, mainly by the lungs and kidneys, keeping arterial pH near 7.35 to 7.45; deviation impairs enzyme function and organ performance.

Routine measurements of temperature, pulse, respiratory rate, blood pressure, and often oxygen saturation that indicate basic physiological status and signal deterioration when abnormal or changing.

A scoring tool that combines routine observations such as respiratory rate, oxygen saturation, blood pressure, pulse, temperature, and consciousness to flag patients at risk of deterioration.

A targeted patient evaluation limited to the system or problem at hand, used to establish current status, detect changes, or monitor response to an intervention rather than to survey the whole body.

Information the patient or family reports that the clinician cannot directly measure, such as pain level, nausea, dizziness, or history of present illness.

Measurable findings obtained through observation, examination, and testing, such as vital signs, laboratory values, wounds, and breath sounds.

A blood test measuring arterial pH, carbon dioxide, oxygen, and bicarbonate that reveals oxygenation, ventilation, and acid-base status in seriously ill patients.

A noninvasive method that estimates the percentage of hemoglobin saturated with oxygen using light absorption through tissue; readings can be unreliable with poor perfusion, motion, or certain dyes.

A clinical judgment about a patient's response to health conditions or life processes that provides the basis for selecting interventions within the nurse's scope of practice.

A written, individualized document stating a patient's identified problems, measurable goals, planned interventions, and evaluation criteria, updated as the patient's condition changes.

A patient goal written to be specific, measurable, achievable, relevant, and time-bound, so that progress can be objectively judged and the plan revised accordingly.

A structured, often multidisciplinary plan mapping the expected steps of care for a defined condition or procedure over a set timeline, used to standardize practice and reduce variation.

Systematic comparison of the patient's actual status with the goals set in the care plan to decide whether to continue, revise, or discontinue interventions.

A model describing the six links required for infection to spread: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host; breaking any link prevents transmission.

Infection control practices applied to every patient regardless of diagnosis, including hand hygiene, gloves, gowns, masks, safe sharps handling, and safe waste disposal.

Cleaning hands with soap and water or alcohol-based rub at defined moments, the single most effective routine measure for preventing transmission of pathogens between patients and staff.

An infection acquired by a patient during care in a health facility that was not present or incubating at admission, often linked to devices, procedures, or lapses in infection control.

A continuous, data-driven effort to measure processes and outcomes, identify gaps, test changes, and sustain gains in the safety and effectiveness of care.

The defined line of authority and reporting within an organization that staff follow to escalate concerns, request resources, or report unsafe conditions.

A workplace climate in which any team member is expected and supported to voice safety concerns or question an order without fear of reprisal.

A patient's voluntary agreement to a procedure or treatment after receiving and understanding information about its purpose, risks, benefits, and alternatives, given without coercion.

The professional and legal duty to protect a patient's health information from unauthorized access, use, or disclosure, sharing it only with those who need it for care or as permitted by law.

The principle that only the least amount of protected health information needed for a specific purpose should be accessed, used, or disclosed.

The formal, chronological documentation of a patient's assessments, interventions, test results, and communications, serving as a legal record and a tool for continuity of care.

A written statement made while a patient has decision-making capacity that records future treatment preferences or names a substitute decision-maker for when the patient cannot speak for themselves.

Activities that help people maintain or improve health by addressing lifestyle, environment, and social conditions, rather than only treating existing disease.

Measures taken before disease occurs to reduce risk, such as immunization, safe water, physical activity programs, and smoking prevention.

Testing apparently healthy people to detect disease or risk factors at an early stage when treatment is more effective, such as blood pressure checks or cancer screening programs.

The conditions of birth, growth, living, working, and aging, including income, housing, education, and food security, that shape health outcomes and access to care.

A person's ability to obtain, understand, and use health information to make informed decisions; low health literacy calls for plain language, teach-back, and simpler instructions.