EHPLE Nursing key terms

A written or verbal statement made while a person still has decision-making capacity, naming a surrogate or recording treatment preferences so care can follow the patient's wishes after capacity is lost.

A patient's voluntary agreement to a procedure after receiving and understanding its purpose, risks, benefits, and alternatives; the nurse verifies understanding and witnesses the signature rather than obtaining consent personally.

The ethical duty to act in ways that promote the patient's welfare and prevent harm, balancing potential benefits against burdens when planning interventions.

The ethical obligation to avoid causing harm, including refraining from interventions whose risks outweigh likely benefit.

Respect for a person's right to make self-determined choices about their own health care, even when the care team disagrees with the decision.

Acting on behalf of a patient to protect rights, safety, and preferences, especially when the person cannot speak for themselves or feels pressured.

Failure to provide the care a reasonably prudent nurse would give in similar circumstances, resulting in injury; proof requires duty, breach, causation, and damages.

The defined hierarchy a nurse follows to escalate a concern about unsafe care, moving from charge nurse to supervisor to administrator or risk management.

A confidential internal record documenting an unexpected event or near miss; it supports quality improvement and is not placed in the patient's chart.

The single most effective way to prevent health care-associated infection; alcohol-based rub is used for routine decontamination, and soap and water when hands are visibly soiled or after caring for a patient with C. difficile.

Infection-control practices applied to every patient regardless of diagnosis, including gloves, gown, mask, eye protection based on anticipated exposure, and safe handling of sharps and body fluids.

Practices that keep objects and areas free of all microorganisms, used for invasive procedures such as catheter insertion, dressing changes, and surgery.

A scored assessment of pressure injury risk using six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear; lower scores indicate higher risk.

Classification of localized tissue damage by depth: stage 1 intact skin with nonblanchable redness, stage 2 partial-thickness loss, stage 3 full-thickness loss, stage 4 extending to fascia, bone, or muscle; unstageable and deep tissue injury are separate categories.

Planned turning of an immobile patient, commonly every two hours or per individualized assessment, to relieve pressure over bony prominences and prevent tissue breakdown.

Measurement and recording of all fluids entering and leaving the body, used to assess hydration, renal function, and response to diuretics or intravenous therapy.

Weighing a patient at the same time each day, on the same scale, with similar clothing; a change of 1 kg approximates 1 liter of fluid gained or lost.

A state in which water and electrolytes are lost faster than replaced, producing thirst, tachycardia, hypotension, decreased urine output, and poor skin turgor.

Shift of fluid from the vascular space into a nonfunctional compartment such as the peritoneal cavity or burned tissue, causing edema while effective circulating volume falls.

Worsening of cardiac pumping ability marked by dyspnea, orthopnea, crackles, dependent edema, and weight gain, usually managed with diuretics, oxygen, and position of comfort.

Chest discomfort from myocardial oxygen demand exceeding supply; stable angina is predictable with exertion, while unstable angina occurs at rest or with increasing frequency and signals acute coronary syndrome.

Death of heart muscle from prolonged ischemia, typically presenting with crushing chest pain, diaphoresis, nausea, and ST-segment changes; women and older adults may report atypical symptoms.

Cardiac muscle protein released into blood when myocytes are damaged; elevated values support the diagnosis of myocardial infarction and rise within hours of onset.

Sublingual dosing for anginal pain, taken at onset and repeated up to three times five minutes apart; hold and notify the provider if systolic blood pressure falls below about 90 mm Hg.

Gravida counts all pregnancies including the current one; para counts births after 20 weeks regardless of outcome, so a woman in her second pregnancy with one term birth is gravida 2, para 1.

New blood pressure of 140/90 mm Hg or higher after 20 weeks' gestation without proteinuria or organ dysfunction; preeclampsia adds proteinuria or end-organ findings and warrants closer surveillance.

Anticonvulsant given for seizure prophylaxis in preeclampsia and eclampsia; the nurse monitors deep tendon reflexes, respiratory rate, and urine output and keeps calcium gluconate available as the antidote.

Continuous or intermittent recording of fetal heart rate and uterine contractions to detect hypoxia; late decelerations suggest uteroplacental insufficiency and require repositioning and provider notification.

Rapid newborn assessment at one and five minutes after birth scoring heart rate, respiratory effort, muscle tone, reflex irritability, and color from 0 to 2 each, for a maximum of 10.

The newborn's limited ability to conserve heat, managed with skin-to-skin contact, warm blankets, and delayed bathing to prevent cold stress and hypoglycemia.

Yellowing from elevated bilirubin in the first days of life; pathologic jaundice appears within 24 hours, and phototherapy is used when levels are high or rising quickly.

Inadequate growth in weight or length compared with expected norms for age, often from feeding difficulty, chronic illness, or psychosocial factors, requiring a full nutritional and developmental evaluation.

Expected developmental achievements such as head control, sitting, walking, and first words; persistent delay in one domain warrants referral for early intervention.

Purposeful use of open questions, reflection, silence, and clarification to help a patient express feelings and reach insight, avoiding advice-giving and false reassurance.

Structured inquiry about ideation, plan, intent, means, and protective factors to determine level of observation and need for safety precautions such as removing ligature points.

Rare, life-threatening reaction to antipsychotic drugs marked by high fever, muscle rigidity, altered mental status, and autonomic instability; the drug is stopped immediately and emergency treatment begun.

The blood concentration range in which a medication produces benefit with acceptable toxicity; levels outside it prompt dose adjustment, such as with lithium, digoxin, or phenytoin.

Verification of the right patient, drug, dose, route, time, and documentation, with two identifiers used; high-alert medications add an independent double check.

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

Primary prevention stops disease before it starts through immunization and education; secondary detects it early through screening; tertiary limits disability through rehabilitation and chronic disease management.

A condition that must be reported to public health authorities so outbreaks can be tracked and controlled; examples include tuberculosis, measles, and selected sexually transmitted infections.

A person's ability to obtain and understand health information to make decisions; low literacy calls for plain language, teach-back, and visual aids rather than written handouts alone.