CMSRN key terms

A life-threatening organ dysfunction caused by the body's dysregulated response to infection. Signs include fever or hypothermia, tachycardia, tachypnea, hypotension, and altered mental status. Early recognition and treatment in the first hours improve survival.

An acute, fluctuating disturbance of attention and awareness developing over hours to days, often triggered by infection, medications, pain, or an unfamiliar environment. It is potentially reversible and distinct from dementia; prevention and early recognition are nursing priorities.

A six-item risk assessment that scores sensory perception, moisture, activity, mobility, nutrition, and friction or shear to predict pressure injury risk. Lower scores indicate higher risk and prompt prevention such as repositioning, support surfaces, and nutrition support.

A scored fall-risk screening tool based on history of falling, secondary diagnoses, ambulatory aids, intravenous therapy, gait, and mental status. Higher scores trigger interventions such as bed alarms, hourly rounding, and nonskid footwear.

A focused check of circulation and nerve function in a limb, commonly remembered as the six Ps: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness). Changes are reported immediately because they may signal compartment syndrome.

Blood glucose below about 70 mg/dL, producing shakiness, sweating, hunger, confusion, or seizures. Conscious patients receive fast-acting oral carbohydrate; unconscious patients need IV dextrose or glucagon. Glucose is rechecked after treatment.

Excess extracellular fluid causing weight gain, edema, crackles, jugular venous distention, and dyspnea. Nursing actions include daily weights, strict intake and output, lung sound assessment, upright positioning, and administering prescribed diuretics.

A urinary tract infection occurring in a patient who has or recently had an indwelling urinary catheter. Prevention centers on avoiding unnecessary catheters, aseptic insertion, maintaining a closed drainage system, and removing the catheter as soon as possible.

An adverse response to a blood product such as fever, chills, hives, dyspnea, flank pain, or dark urine. The nurse stops the transfusion, keeps the line patent with normal saline, assesses the patient, and notifies the provider and blood bank.

A dangerous decrease in breathing rate and depth caused by opioids, usually preceded by increasing sedation. Nurses monitor respiratory rate, depth, and sedation level, use prescribed monitoring, and give naloxone to reverse the effect when indicated.

Any physical or chemical measure limiting a patient's freedom of movement, used only after less restrictive alternatives fail. It requires a provider order with time limits, ongoing monitoring, periodic release, and documentation.

Systematic evaluation of pain using the patient's self-report as the gold standard, with numeric, facial, or verbal scales chosen by age and ability. Nonverbal patients are assessed with behavioral tools, and reassessment follows every intervention.

Measures that reduce the risk of stomach contents entering the lungs during tube feeding, including elevating the head of the bed 30 to 45 degrees, checking residual volume per policy, confirming tube placement, and pausing feeding before procedures.

A serum potassium level above normal that can cause muscle weakness, paresthesia, and life-threatening ventricular arrhythmias such as peaked T waves. Treatment includes cardiac monitoring, IV calcium, insulin with glucose, and potassium-removing agents.

A teaching technique in which the learner explains or demonstrates information back in their own words. It reveals misunderstandings and lets the nurse reteach, confirming the patient can act safely at home.

The degree to which a person can obtain, understand, and use health information to make decisions. Low health literacy is common and often hidden; plain language, pictures, and small amounts of information improve comprehension.

A patient's physical, emotional, and cognitive ability and willingness to receive instruction. Pain, fatigue, anxiety, or crisis block learning, so teaching is timed for when the patient is comfortable, alert, and receptive.

A collaborative, goal-oriented counseling style that helps patients find their own reasons for change. The nurse uses open questions, reflective listening, and affirmation rather than advice or argument, strengthening the patient's own commitment.

The three categories of learning: cognitive (knowledge and facts), affective (attitudes, beliefs, feelings), and psychomotor (physical skills). Effective patient education addresses the domain that matches the behavior being taught.

Structured education preparing a patient and family to manage care after leaving the hospital, covering medications, activity, diet, wound care, warning signs, follow-up appointments, and whom to call with questions.

An ongoing self-reflective practice of recognizing one's own biases and power while learning about each patient's values, beliefs, language, and preferences. It supports respectful, individualized care and teaching rather than assumptions based on group identity.

Assigning a specific nursing task to another team member while retaining accountability for the outcome. It follows the five rights: right task, right circumstance, right person, right direction and communication, and right supervision and evaluation.

The range of duties, responsibilities, and activities a nurse is legally permitted to perform, defined by state nurse practice acts, licensure, and facility policy. Nurses must decline or question tasks outside that scope.

The formal hierarchy of authority used to communicate concerns, escalate unsafe situations, or obtain decisions. Staff are expected to use it when a patient is deteriorating and the immediate provider is unresponsive.

Acting on behalf of a patient to protect their rights, safety, preferences, and access to care. The nurse speaks up for the patient, supports informed choices, and questions orders or conditions that threaten well-being.

A workplace approach that responds to human error with support and learning while holding people accountable for reckless or knowingly unsafe behavior. It encourages reporting and improves safety without a blame-first response.

The patient's voluntary agreement to treatment after receiving information about its purpose, risks, benefits, and alternatives. Providers obtain consent; nurses verify understanding, witness signatures, and confirm the patient is competent and not coerced.

A legal duty to report specified conditions, such as suspected abuse or neglect of children, older adults, or vulnerable persons, certain communicable diseases, and unsafe providers, to the designated authority.

Clinical decision-making that integrates the best available research with the nurse's expertise and the patient's values and preferences. It commonly begins with a clinical question framed in PICO format.

Deciding which patient needs or nursing actions come first, typically ranking life-threatening problems (airway, breathing, circulation) above urgent and then routine concerns, and acute changes above chronic issues.

A structured communication format for handoffs and escalations: Situation, Background, Assessment, and Recommendation. It gives the receiver concise, organized information and ends with a clear request for action.

The transfer of responsibility and essential patient information between caregivers or settings. A standardized format with an opportunity for questions reduces omissions, errors, and harm during shift changes and transfers.

A formal process of obtaining a complete medication list, comparing it with new orders, and resolving discrepancies at admission, transfer, and discharge to prevent omissions, duplications, and harmful interactions.

A group of professionals from different disciplines, such as nursing, medicine, pharmacy, therapy, and social work, who share goals and coordinate care for a patient. Respectful communication and clear role understanding improve outcomes.

A process of coordinating care, resources, and services for a patient across the continuum, focusing on appropriate level of care, cost, and outcomes. Case managers often arrange post-acute placement, equipment, and community support.

The movement of a patient between settings, units, or providers, such as hospital to home or nursing facility. Safe transitions require timely information exchange, medication reconciliation, and teaching about self-care.

A structured approach to disagreements among team members or with patients and families, using respectful assertive communication, focusing on interests rather than personalities, and seeking a mutually acceptable plan.