PNLE key terms

A systematic, cyclic five-step method - assessment, diagnosis, planning, implementation, and evaluation - that nurses use to identify patient problems and to plan, deliver, and judge care.

A clinical judgment about an individual's, family's, or community's response to actual or potential health problems, which guides the selection of nursing interventions and measurable outcomes.

Transferring the authority to perform a specific task to a competent assistive worker while the nurse keeps accountability for the decision, the supervision, and the outcome of that task.

Being answerable for one's own actions, decisions, and omissions, including reporting errors honestly and accepting the results of work that one has delegated to others.

The activities and responsibilities a nurse may legally perform and is competent to carry out, set by law, licensure, and the policies of the workplace.

The degree of care and skill a reasonably prudent nurse with similar education and experience would give a patient in comparable circumstances; it is the benchmark used in negligence cases.

Professional negligence by a nurse that harms a patient, proven by four elements: a duty was owed, the standard of care was breached, the breach caused the injury, and damages resulted.

The ethical principle that a competent patient has the right to make informed decisions about their own care, including accepting or refusing recommended treatment.

A patient's voluntary agreement to a procedure after receiving and understanding information about its purpose, risks, benefits, and alternatives; the nurse verifies and witnesses but does not obtain it.

A written statement made while a person is still competent that records future health care wishes or names someone to decide for them when they can no longer speak.

Clinical decision-making that blends the best available research evidence, the nurse's own expertise, and the patient's values and preferences in order to deliver high-quality care.

A structured format for building a searchable clinical question: the population or patient problem, the intervention, the comparison, and the outcome of interest.

The total number of times a woman has been pregnant, including the current pregnancy, regardless of whether those pregnancies ended in birth, miscarriage, or abortion.

The number of pregnancies a woman has carried to the age of viability, usually 20 weeks or more, whether the infant was born alive or stillborn.

A shorthand obstetric history covering gravida, term births, preterm births, abortions or miscarriages, and living children, giving a quick picture of a woman's pregnancy outcomes.

The distance in centimeters from the symphysis pubis to the top of the uterus, measured from about 20 weeks to estimate fetal growth and gestational age.

Four abdominal palpation steps performed in late pregnancy to determine fetal lie, presentation, position, and attitude before auscultating the fetal heart rate.

New high blood pressure that appears after 20 weeks of pregnancy together with protein in the urine or signs of organ damage, and that can progress to seizures called eclampsia.

Blood loss greater than 500 mL after a vaginal birth or 1000 mL after a cesarean birth, or any loss that makes the mother unstable; uterine atony is the usual cause.

The vaginal discharge of blood, mucus, and uterine tissue after childbirth, which changes from red (rubra) to pink-brown (serosa) to white-yellow (alba) over several weeks.

A quick newborn assessment at one and five minutes after birth that scores heart rate, breathing effort, muscle tone, reflex response, and color from zero to two each.

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

A handheld device and breathing exercise that encourages slow, deep, sustained inhalation to keep the lungs expanded and to prevent atelectasis and pneumonia after surgery.

Repeat assessment of a limb's color, warmth, capillary refill, pulses, movement, sensation, and pain to detect circulatory or nerve compromise before permanent damage occurs.

A fall in blood pressure when a person stands, usually defined as at least 20 mmHg systolic or 10 mmHg diastolic, causing dizziness and suggesting low blood volume.

The movement of fluid into a space where it cannot circulate, such as the abdominal cavity or injured tissue, producing swelling while the bloodstream becomes depleted.

A life-threatening result of severe insulin lack, with very high blood glucose, ketone buildup, and metabolic acidosis, treated with intravenous fluids, insulin, and electrolyte replacement.

A blood glucose below about 70 mg/dL causing sweating, shakiness, hunger, confusion, or seizures; a conscious patient is given 15 grams of fast-acting carbohydrate and then rechecked.

The difference between the apical and radial rates counted at the same time, showing that some heartbeats are too weak to produce a pulse at the wrist.

Planned, goal-directed interaction that uses active listening, open-ended questions, empathy, and reflection to help a patient express feelings and work through problems.

The patient's unconscious shifting onto the nurse of feelings, wishes, and expectations that originally belonged to an important person from the patient's past, such as a parent.

The nurse's unconscious emotional reaction to a patient that comes from the nurse's own past relationships and can cloud judgment if it is not recognized and managed.

An automatic, unconscious mental strategy that reduces anxiety by distorting, ignoring, or explaining away reality, such as denial, projection, or rationalization.

Deliberately using the physical setting, daily routines, and social interactions of a psychiatric unit as treatment to promote safety, self-care skills, and contact with reality.

A fixed false belief that is not shared by the person's culture and does not change when faced with clear evidence, such as the certainty of being watched or poisoned.

A sensory experience - hearing, seeing, smelling, tasting, or feeling something - that happens without any outside stimulus and feels completely real to the person.

Movement side effects caused by dopamine-blocking antipsychotic drugs, including acute dystonia, parkinsonism, akathisia, and tardive dyskinesia, which may require a medication change.

A rare, life-threatening reaction to antipsychotic medication with high fever, severe muscle rigidity, confusion, and unstable vital signs, needing immediate stopping of the drug and emergency treatment.