UP CNET key terms

A systematic five-step method of clinical reasoning and care delivery: assessment, diagnosis, planning, implementation, and evaluation. It structures how nurses collect data, set goals, act, and judge whether outcomes were achieved.

A clinical judgement about a patient's actual or potential health response to illness, written in a standard format with problem, cause, and defining signs. It guides selection of nursing interventions rather than medical treatment.

A written document listing a patient's identified problems, measurable goals, planned nursing interventions, and evaluation criteria. It coordinates care across shifts and is updated as the patient's condition changes.

The final step of the nursing process, comparing the patient's actual status against the stated goals to decide whether care continues, is revised, or is discontinued. Judgements must be based on recorded, measurable evidence.

Body temperature, pulse, respiratory rate, blood pressure, and often oxygen saturation, measured to detect physiological change. Frequency of measurement is set by the patient's condition and institutional protocol.

A numeric score calculated from routine observations such as respiratory rate, oxygen saturation, blood pressure, pulse, temperature, and consciousness. Rising scores trigger escalating clinical review before deterioration becomes irreversible.

A non-invasive method of estimating arterial oxygen saturation by measuring light absorption through a pulsatile vascular bed. Readings are unreliable in poor perfusion, motion artifact, nail polish, or severe anemia.

Practices that prevent microorganisms from entering a susceptible site. Medical asepsis reduces pathogen spread through cleanliness; surgical asepsis eliminates all microorganisms from objects and the field using sterile technique.

Minimum infection-prevention measures applied to every patient regardless of diagnosis, including hand hygiene, gloves, gown, mask, eye protection, safe sharps handling, and safe waste disposal. They replace the older category of universal precautions.

Additional isolation measures used with standard precautions for patients with known or suspected pathogens, grouped as contact, droplet, and airborne precautions. Each requires specific room placement and personal protective equipment.

Isolation measures for pathogens spread by small droplet nuclei that remain suspended in air, such as tuberculosis, measles, and varicella. They require a negative-pressure room and a fit-tested N95 respirator for entry.

Cleaning hands with soap and water or alcohol-based rub at defined moments of patient contact. It is the single most effective measure for preventing healthcare-associated infection and applies before and after every care episode.

The set of policies and practices that prevent and contain healthcare-associated infections, covering surveillance, isolation, sterilization, antibiotic stewardship, and staff education. Its effectiveness is measured through infection rates and audit compliance.

A rapid sorting process that ranks patients by urgency so that limited resources go first to those who will benefit most. It is used in emergency departments, disasters, and battlefield settings with defined colour or category systems.

An assigned urgency level, often colour-coded, that determines the maximum acceptable waiting time before medical assessment. Categories are reassessed when the patient's condition or the department's workload changes.

The checks performed before every drug administration: right patient, right drug, right dose, right route, right time, and right documentation, with right reason and right response often added. They are verified using at least two patient identifiers.

A drug that carries a heightened risk of serious harm when used incorrectly, such as insulin, heparin, concentrated electrolytes, and opioids. Such drugs require independent double-checks, standardized concentrations, and restricted storage.

Any preventable event that may cause or lead to inappropriate medication use or patient harm, including prescribing, transcribing, dispensing, administering, and monitoring failures. Reporting systems aim at system improvement rather than individual blame.

Administration of fluids, electrolytes, or drugs directly into a vein through a cannula, giving rapid systemic effect. Nurses calculate flow rates, monitor the site for infiltration, and observe for fluid overload and phlebitis.

The comparison of all fluid taken in by mouth, tube, or vein against fluid lost through urine, stool, vomit, drains, and insensible routes. Accurate charting detects dehydration and overload early.

A bedside record quantifying every fluid entering and leaving the body over a set period, usually 24 hours. It is essential in renal, cardiac, and postoperative care and must include insensible losses in interpretation.

Localized damage to skin and underlying tissue over a bony prominence, caused by sustained pressure combined with shear, friction, or moisture. Staging describes depth from non-blanchable redness to full-thickness tissue loss.

A validated tool scoring six risk factors, including sensory perception, moisture, activity, mobility, nutrition, and friction, to predict pressure injury risk. Lower total scores indicate higher risk and prompt preventive measures.

Regularly changing a patient's body position to relieve pressure over bony prominences and maintain circulation. Frequency is individualized, commonly every two to four hours, and documented with skin inspection at each turn.

Systematic evaluation of pain using a validated scale appropriate to the patient, such as numeric rating, visual analogue, or behavioural tools for those unable to self-report. It records location, quality, intensity, timing, and effect on function.

A standardized instrument converting a patient's pain experience into a comparable score, for example 0 to 10 numeric rating or Wong-Baker faces. The same tool should be reused to judge response to analgesia.

Administration of supplemental oxygen to correct hypoxaemia, delivered by nasal cannula, mask, or high-flow device. Flow and target saturation are prescribed, and patients with chronic carbon dioxide retention need controlled levels.

Assessment and intervention to keep the upper airway open and clear, including positioning, suctioning, airway adjuncts, and bag-mask ventilation. It is the first priority in any resuscitation sequence.

Emergency chest compressions and rescue breaths, with early defibrillation, used to restore circulation in cardiac arrest. High-quality compressions at adequate rate and depth with minimal interruption improve survival.

Delivery of a controlled electric shock across the chest to terminate a shockable rhythm such as ventricular fibrillation or pulseless ventricular tachycardia. It is time-critical and must follow immediate recognition and CPR.

A recording of the heart's electrical activity through surface electrodes, displaying P waves, QRS complexes, and T waves. Nurses use it to detect arrhythmias, ischaemia, and electrolyte disturbances.

Insertion of a sterile tube through the urethra into the bladder to drain urine, used for retention, monitoring, or bladder irrigation. It carries infection risk and should be removed as soon as no longer indicated.

Cleaning, assessing, and dressing a wound to promote healing and prevent infection, choosing dressing type by wound bed, exudate, and depth. Each change includes measurement and documentation of healing progress.

Evaluation of a patient's nutritional status using history, anthropometry, biochemical markers, and clinical examination. It identifies malnutrition risk that affects wound healing, immunity, and recovery.

Weight in kilograms divided by height in metres squared, used to classify underweight, normal, overweight, and obesity. It is a screening index and does not distinguish muscle from fat or reflect fluid status.

Planned teaching that gives patients and families the knowledge and skills to manage health, treatment, and self-care. Readiness, literacy, language, and cultural context determine the method and content used.

A patient's voluntary agreement to a procedure after receiving adequate information about its nature, benefits, risks, and alternatives. The clinician performing the procedure obtains it; the nurse verifies and witnesses it.

Entitlements owed to every person receiving care, including respect, privacy, confidentiality, information, choice, and complaint without penalty. They are protected by law, professional codes, and institutional charters.

The professional duty to keep patient information private and share it only with those who need it for care. Breach may be legal and ethical, with narrow exceptions such as statutory reporting or serious public risk.