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NP&P Unit 2
| Term | Definition |
|---|---|
| Informatics | The use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. |
| Simulation | Is a method used to create a situation that mimics a real experience and is used for the practice, assessment, education, or to acquire knowledge of system's or a person's actions. |
| Clinical Decision Making | An iterative process using nursing knowledge to assess a client situation, identify the priority concern, then use evidence-based interventions to implement care. |
| Clinical Information System | Computer systems that allow for instant retrieval of client information either directly or from data networks. |
| Information Technology | Technology and physical devices used to create and store information, including electronic health records |
| Electronic Health Record (EHR) | Systemic, digitized documentation system used to improve medical records. A computerized, real-time form of a client's paper chart that can be shared between members of the interprofessional team. |
| EHR Examples | Information such as the medical history, diagnosis, allergies, and diagnostic testing results. |
| Clinical Pathways | A standardized method of health care delivery for a specific group of clients through the use of practices based on evidence-based guidelines. |
| Quality Improvement | A systematic process of analyzing care practices to maintain the highest levels of client care and outcomes. |
| Health Insurance Portability and Accountability Act | The Health Insurance Portability and Accountability Act, also known as the Privacy Act, legislation to protect coverage and private information of clients. |
| Protected Health Information (PHI) | Any information held by a covered entity that can be linked to an individual. |
| Common HIPAA Violations | -Unsupervised Access to PHI -Data Disposal -Denying Access to PHI -Disclosing PHI -Loss of PHI |
| Unsupervised Access to PHI | Access to and use of personal health information is restricted to only the personnel who are providing direct care to a client or are performing research as a part of clinical assignments. |
| Data Disposal | Improperly discarding or failing to destroy PHI when it is no longer being used is a HIPAA violation. This includes written as well as electronic information. |
| Denying access to PHI | Clients have a right to access their health records and obtain copies upon request |
| Disclosing PHI | Information contained as a part of a client's PHI should only be shared with members providing direct care to the client or third-parties such as an insurance company if a HIPAA authorization form to share PHI is signed by the client or their designee. |
| Loss of PHI | Unauthorized disclosure of client PHI is a violation of the HIPAA Security Rule, even if this occurs as the result of loss or theft. Commonly seen when health care staff take work computers. |
| Telehealth | The provision of both clinical and nonclinical aspects of health care delivery through the use of telecommunication devices such as the internet and telephone. |
| Adverse Drug Event (ADE) | An injury caused from a medical intervention that is linked to a medication. |
| Medication Error | Preventable error capable of causing harm or death to a client under the care of a health care provider. |
| Health Literacy | The ability to obtain, read, and understand health-related information |
| 5 Pillars of Meaningful Use | -Ensure Privacy & Security -Improve Population Health -Improve Safety & Quality -Engage Patient & Families -Coordinate Care |
| Pharmacokinetics | Study of the absorption, metabolism, distribution, and excretion of drugs in the human body. |
| Ionization | Affects the degree of absorption and the rate at which the drug permeates the cell membranes, which ultimately impacts the distribution of a medication. |
| Dissolution | Medication must be dissolved in solution before absorption takes place. The dissolution of a medication is dependent upon its initial state and route of administration. |
| Orally Disintegrating Tablets | Drug form that rapidly dissolves on the tongue or oral cavity. |
| Enteral Route | Medications administered via the mouth, stomach or intestines. |
| Dose | The amount of the ordered medication. |
| Toxicity | An adverse effect in which the body is unable to metabolize or excrete a medication; it can cause irreversible damage to organs. |
| Prodrugs | Contain inactive chemicals that are activated through metabolism to exert their therapeutic effects. |
| Therapeutic Effects | The desired effects of a medication. |
| First Pass Effect | The passage of oral medications from the small intestine to the hepatic circulation via the mesenteric and portal veins flowing into the liver, before reaching systemic circulation. |
| Pharmacodynamics | The study of how a drug works, its relationship to drug concentrations, and how the body responds. |
| Therapeutic Range | A method used by health care providers to monitor drug concentrations to determine therapeutic dose and avoid toxicity. |
| Therapeutic Drug Monitoring | Method used by health care providers to monitor drug level concentrations. |
| Peak Blood Level | Highest level of a drug in the bloodstream without being at a toxic level. |
| Trough Blood Level | Lowest concentration of a medication in the systemic circulation. |
| Half Life | Time it takes for the drug to fall to half its strength through excretion. |
| Adverse Drug Reaction (ADR) | Unwanted and non-therapeutic effects of the medication. They can range from mild to severe. |
| Iatrogenic | An unforeseeable or unintended physical condition, injury, or disorder caused by a treatment or procedure. |
| Allergic Reaction | A reaction resulting from a hypersensitivity to an antigen or foreign substance, such as a medication. |
| Anaphylaxis | An acute allergic reaction to an antigen that may result in life-threatening shock, producing vasodilation, bronchospasm, and laryngeal edema. |
| Drug to Drug Interactions | The effect that two or more drugs that the client is administered have on each other (ex. enhance actions or block actions, increase or decrease ADR etc). |
| Drug to Food Reactions | Effects of nutrients on the absorption, distribution, metabolism or excretion of medications. |
| Teratogenic | Medications that can cause fetal defects, pregnancy loss, prematurity or developmental disabilities. |
| Polypharmacy | Multiple medications that one person is taking. |
| The Rights of Medication Administration | -Right; Client -Right; Medication -Right; Dose -Right; Route -Right; Time -Right; Assessment -Right; Documentation -Right; to Refuse (PT) -Right; Education -Right; Evaluation |
| Ways to Verify Right Client | -Name -Date of Birth -Medical Record Number (MRN) |
| Medication Administration Record (MAR/E-MAR) | A record of the medications prescribed for the client by the provider. The MAR is used by the nurse to record and confirm medication administration per the prescription. |
| Generic | Non-trademarked name of a drug assigned by the Food and Drug Administration. |
| STAT Medication Prescription | Medications that are required to be given immediately. |
| PRN | As needed. medications given as required for specific conditions or issues, such as pain, nausea, etc. |
| Time Critical Medications | Medications that should be given within either 30 minutes before or after the scheduled administration time. |
| Non-Time Critical Medications | Medications that can be administered between 1 to 2 hours before or after the scheduled time without causing harm or resulting in substandard pharmacologic effects to the client. |
| Prescription | A medication order written by the provider that includes the name of drug, amount to be give, the route and frequency of administration. The order needs to have the client s name, the date and time the order was written and the provider s name and title. |
| Factors Contributing to Medication Errors pt.1 | -Failure to follow the rights of medication administration -Failure to check for accuracy of the medication prescription |
| Factors Contributing to Medication Errors pt.2 | -Failure to assess the client for any high-risk variables related to age, disease states, laboratory data, allergies, and prior response to medications. -Giving medications before they can be verified by the pharmacist and other members of the team. |
| Factors Contributing to Medication Errors pt.3 | -Incomplete or illegible prescriptions with missing components of the medication prescription. Unofficial abbreviations should not be accepted. -Working under stressful conditions with numerous interruptions. |
| Over-The-Counter Medication | Medications that can be purchased without a healthcare providers prescription. |
| Override | The nurse removes a medication from the automatic dispensing system before the pharmacist has reviewed the order. |
| Workaround | The practice of avoiding a policy or procedure in a system that is there to protect client safety. |
| Strategies to Reduce Medication Errors pt.1 | -Identify client by using two types of identifiers -Use appropriate administration techniques for the prescribed medications. Use aseptic technique when administering parenteral medications |
| Strategies to Reduce Medication Errors pt.2 | -Calculate all doses of medications correctly, with a double-check for complicated calculations, high-risk medications, IV medications, and pediatric dosages -Be alert for sound-alike medications |
| Strategies to Reduce Medication Errors pt.3 | -Clarify any questions or concerns about the medication prescription with the health care provider. -Never leave any medications at the bedside. |
| Strategies to Reduce Medication Errors pt.4 | -Always have another nurse witness insulin doses and disposal of unused narcotic doses, as required by the facility. -Educate clients when all new medications are prescribed or when they have questions. |
| Strategies to Reduce Medication Errors pt.5 | -Become familiar with the medication prior to administration by consulting a drug reference guide, the health care provider, the pharmacy, or a facility approved application on an electronic device. -Confirm client allergies. |
| Strategies to Reduce Medication Errors pt.6 | -Recognize that the client has the right to refuse medications. -Observe and assess the client prior to medication administration and following the administration of any PRN or new medications for efficacy and adverse medication effects. |
| Unit Dose Medication | A medication that is prepared and packaged by the hospital’s pharmacists or the drug manufacturer in a single unit dose container that is specific to the provider’s prescription for the client. |
| Multi Dose Vial | A container of medication that holds more than a single dose of medication and can be used for multiple clients. |
| Common Routes of Medication Administration | -Oral (PO) -Sublingual (SL) -Rectal (PR) -Intravenous (IV) -Buccal -Inhalation -Intramuscular (IM) -Subcutaneous (Sub-Q/Subcut) -Transdermal |
| Buccal Route | Administration of a tablet by placing it in the oral cavity between gum and cheek. |
| Enteric-Coated | Medications that are formulated to be dissolved and released in the small intestines for a slower release and can be administered less frequently during the day. |
| Sustained Release | Tablets designed to release medication slowly over an extended period. |
| Transdermal | Delivery of a specially prepared medication designed to be absorbed by the skin. |
| Ophthalmic | Pertaining to the eyes. |
| Otic | Pertaining to the ears. |
| Nasal | Medication administered via the nostrils. |
| Vaginal Route | Delivery of a specially prepared medication designed to be absorbed through the vaginal mucosa. |
| Rectal Route | Administered via the rectum or anus. |
| Parenteral Route | Medication administered by a route that does not involve the gastrointestinal tract. Usually refers to an injection and is administered by a needle such as intravenous or intramuscular. |
| Ampule | A glass container that stores liquid medication. |
| Intradermal | Medication administered via the dermal layers of the skin. |
| Subcutaneous Route | A medication administered beneath the skin or dermal layer. |
| Lipohypertrophy | The formation of small lumps beneath the skin due to irritated fatty tissue. |
| Intramuscular | Medication administered into a specific muscle. |
| Aspirate | To pull back on the plunger of a syringe after the needle has been inserted, to determine if the needle is within a blood vessel. If it is in a blood vessel, upon aspirating, blood will flow into the syringe. |
| Intermittent Venous Access Device | A peripheral IV catheter inserted via a venipuncture. It is placed for administration of intermittent medication administration to prevent a venipuncture being performed each time an intermittent medication is given. |
| Phlebitis | Inflammation of the vein as evidenced by localized redness, pain, heat and swelling. |
| Infiltration | Intravenous fluid is administered to surrounding tissue as evidenced by pain, swelling, redness, cool skin temperature around insertion site, skin taunt around IV site, oozing of IV fluid at insertion site and repeated alarming of IV pump. |
| deci- | Divide by 10 (1/10) |
| centi- | Divide by 100 (1/100) |
| milli- | Divide by 1,000 (1/1,000) |
| micro- | Divide by 1,000,000 (1/1 millionth) |
| deka- | Multiply by 10 (x*10) |
| hecto- | Multiply by 100 (x*100) |
| kilo- | Multiply by 1,000 (x*1000) |
| Ratio and Proportion | One method of calculating dosages. It uses ratios, which are expressed as fractions and placed in an equation that allows for the comparison of like units, referred to as proportions. |
| Desired over Have | A mathematical equation used to determine the amount of medication to administer to a client. The equation uses two factors; the desired dose to be administered and the dose that is available. |
| Dimensional Analysis | A mathematical formula used to determine the amount of medication to administer to a client. It is helpful when needing to convert units of measure such as mg to mcg. |
| Compliance | Following the healthcare provider s instructions, taking the medication according to the treatment regimen. |
| Quality Improvement (QI) | Proactive, process-driven, systematic actions to improve client outcomes and improve performance in healthcare delivery. |
| Quality Assurance | Reactive, problem-driven measures to improve client outcomes and improve healthcare delivery. |
| Standardization | The process of creating and implementing consistent guidelines, methods, steps, processes, or practices that improve the quality of care and client safety. |
| Structure | The condition or environment in which the care is provided. |
| Process | Measures the mechanisms of the care provided. |
| Outcomes | Includes measurable results that may be positive or negative. |
| Plan, Do, Study, Act Model (PDSA) | A four-step process for quality improvement that includes plan, do, study, act. |
| Process Flow Chart | A visual diagram used to clarify a complex process by providing a visual view of the steps in a sequential manner |
| Histogram | A specific form of a bar chart that displays the distribution of continuous numerical value. |
| Run Chart | A visual aid using lines to connect data points depicting how a process or information has changed over time. |
| Audit | Identifies errors or discrepancies of documentation of nursing care. |
| Continuous Quality Improvement (CQI) | An ongoing measurement, assessment, and improvement of quality initiatives to provide quality care and safety to clients utilizing the QI tools and models. |
| Risk Management (RM) | The identification, evaluation and prioritization of risks to eliminate or mitigate their probability or severity or to leverage opportunities. |
| Adverse Event | Any event that is not consistent with the desired or normal operation. |
| Sentinel Event | Any event causing serious injury or death to a client in healthcare facility. Sentinel events can include, medication error, transfusing the wrong blood type, client suicide, or wrong-site surgery. |
| Never Event | An adverse event that should never occur. |
| Examples of "Never Events" | -Surgical or procedural -Product or device -Client protection -Care management -Environmental -Radiologic -Criminal |
| Route Cause Analysis (RCA) | A systematic process that focuses on identifying the cause of an event and developing an action plan with strategies aimed at preventing future events. |
| Quality Core Measures | Are standardized processes and best practices created to improve client care. |
| Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) | A data collection survey utilized to measure client's perception of their inpatient experience. |
| Cost-Effective | The minimal expense of dollars, time, and other elements used to achieve results. |
| Cost-Effectiveness Analysis (CEA) | Compares health care interventions to see which is most effective for the least amount of money without producing negative client outcomes. |
| Leapfrog Group | A nonprofit organization that conducts free, annual surveys of hospitals and ambulatory care centers on a voluntary basis. Measurements included in the survey align with TJC, CMS, and the Centers for Disease Control and Prevention (CDC). |
| Evidence Based Practice (EBP) | A problem solving approach to client care that uses the most accurate scientific evidence partnered with clinical expertise and client values. |
| Essential Elements of Evidence-Based Practice pt.1 | -Identify a problem: Ask a question. -Search credible sources of evidence: Look for factual information. -Evaluate the findings: Review the information. |
| Essential Elements of Evidence-Based Practice pt.2 | -Implement recommendations: Change interventions. -Review their effectiveness: Do the new interventions improve results? -Disseminate the results: Share the findings with others. |
| Randomized Controlled Trial | A research study in which study participants are randomly divided into 2 or more groups. After being assigned to groups, participants in one group receive the treatment being tested while clients in the other group receive a standard or control treatment. |
| National Patient Safety Goals (NPSGs) | Goals designed to focus on client safety, safe and effective delivery of health care, and recommendations to avoid adverse outcomes. |
| Two Client Identifiers | This is the first part of the NPSG to identify every client using two identifiers accurately. These may consist of the client's name, date of birth, hospital ID number, telephone number, or alternate client-specific documentation. |
| Barcode Scanner | Used at the time of medication administration when both the medication and the client's facility-issued identification band are scanned to ensure the right medication is being administered to the right client. |
| Critical Results | Lab or diagnostic procedure results that are outside the expected reference range and can be life-threatening or potentially fatal if not immediately improved. |
| Anticoagulant Medications | Medications that inhibit the blood's ability to clot. |
| Medication Reconciliation | The process when the physician assesses the current home medications with the newly prescribed drugs. It must be completed on client admission, transfer, or discharge from the hospital. |
| Clinical Alarm System | Audible alert devices that are built into medical equipment. Their function is to provide a warning of a potentially serious event that is occurring. The other feature is that they warn when there is a machine malfunction. |
| Alarm Fatigue | Sensory overload from noise pollution created in part by the numerous distress alerts. |
| Hospital-Associated Infections (HAIs) | Nosocomial infections. Infections that occurred while the client was in the hospital. |
| Suicide | Death resulting from self-injurious behaviors performed with the intent to die. |
| Time Out | A joint commission mandated pause taken by all personnel in the procedure or operating room. This brief suspension allows identifying the correct patient, site, the procedure to be performed. |
| Standards of Compliance | Former National Safety Goals that have been routinely adopted by healthcare professionals and are now retired. |
| Examples of Standards of Compliance | -Medical error prevention -Verification of qualifications and competency of health care staff -Rights and education of clients -Infection control -Management of medications -Emergency preparedness |
| Hourly Rounding | The practice of scheduling (every 1 hour) a member of the nursing staff to see the client and proactively address their needs such as toileting, positioning, pain, and safety checks (siderail and bed position, proximity of call bell to the client, etc.) |
| Rapid Response Team (RRT) | A dedicated group whose responsibility is to bring proactively critical care to the bedside. |
| Near Miss | A potential error or close call that could have caused harm, but was caught and avoided. |
| Client Safety Event | An unexpected event or circumstance that occurred that did not cause harm to the patient but had the potential to. |
| Sentinel Event (Never Event) | A critical, unexpected adverse event or circumstance that caused severe physical or psychological harm to the patient. |
| Incident Report | A tool used to report an adverse event, sentinel event, client safety event, or near miss. |
| Personal Protective Equipment (PPE) | Specially designed equipment that is meant to protect the healthcare worker from contamination, blood or body fluids. This equipment may include masks, eye protection, gown, gloves, and hair caps. |
| Older Adults | A person who is 65 years of age or older. |
| Hospital-Acquired Injury examples | -SSIs. -CAUTIs. -CLABSIs. -Burn or electrical shock. -Blood transfusion incompatibility. -Injury related to a fall or trauma. -Ineffective and unsafe insulin usage. -Deep Vein Thrombosis -Pressure Injury |
| Clients at High Risk | Clients with an increased safety risk. This population can vary in age, medical, or behavioral conditions. It may also include persons with disabilities. |
| Communication Disability | A Person's inability to interact with others in ways that staff will understand. |
| R.A.C.E | Acronym that stands for Rescue, Alarm, Contain, and Extinguish in the event of a fire. |
| P.A.S.S | An acronym that stands for Pull, Aim, Squeeze, and Sweep. It is used to described the steps to activate and use a fire extinguisher appropriately. |
| Types of Fire Extinguishers pt.1 | -Class A: A water-based fire extinguisher for general combustible materials such as paper, wood, plastics, rubber, and cloth. -Class B: A carbon dioxide (CO2)–based fire extinguisher for oils, gasoline, paints, grease, and other caustic materials. |
| Types of Fire Extinguishers pt.2 | Class C: A dry chemical-based fire extinguisher specific for electrical fires, including those involving wiring, fuse boxes, computers, and other electrical devices. |
| Types of Fire Extinguishers pt.3 | Class D: A fire extinguisher for fires involving metals or flammable metal shavings from elements such as titanium, magnesium, potassium, and sodium. Class K: A fire extinguisher specific for kitchen fires involving flammable oils and fats. |
| Types of Fire Extinguishers pt.4 | Class A, B, C: A multipurpose fire extinguisher that contain a dry chemical suitable for use on flammable materials and liquids or electric equipment. |
| Lateral Evacuation | Clients, visitors and staff who are threatened by fire are moved on the same floor to a safe location. |
| Vertical Evacuation | Clients, visitors and staff threatened by fire are relocated to a different floor. |
| Safety precautions during Evacuation (Fire) pt.1 | -Close all doors. -Wrap all clients in a blanket, with a face covering over their face. |
| Safety precautions during Evacuation (Fire) pt.2 | -This step is appropriate for both clients and staff members. -When moving through the hallways, stay low to the ground, because smoke rises. If necessary, crawl on the floor to reach safety. -Do not run or panic, and do not allow others to do so. |
| Bullying | Recurring behavior of unwelcome action(s) intended to harm, humiliate, or distress another. |
| Active Shooter Priority Actions | Run: Run away from the assailant, if possible. Hide: If people cannot run from the assailant, then they should hide in a secure environment. Fight: If neither running away nor hiding is an option, then fight for your life against the active shooter. |
| Three Categories of Radiation (Alpha) | Alpha: The least amount of risk. Alpha radiation does not penetrate clothing, and it travels only a few centimeters. The possibility of health hazards from exposure to alpha radiation is minor. |
| Three Categories of Radiation (Beta) | Beta: The middle level of risk. Beta radiation travels a small distance. Specialized clothing is needed to prevent exposure. The possibility of health hazards from exposure to beta radiation is minimal. |
| Three Categories of Radiation (Gamma) | Gamma: Gamma radiation can travel in a greater distance, penetrating through clothing and body tissue. Protection from exposure requires lead shielding. The possibility of health hazards from exposure to gamma radiation is high. |
| Elopement | A client leaves or wanders away from a health care facility. Usually due to a diminished mental capacity such as a traumatic brain injury or dementia. |
| Fall | Unplanned descent to the floor with or without injury. |
| Factors that may contribute to a Client Falling | -Stroke -Amputation -Recent surgery -Multiple sclerosis -Visual impairment -Chronic pain -Malnutrition -Weakness -Unsteady gait |
| Cognitive Influences that may contribute to a Client Falling | -Sleep disorders -Impulsiveness -Disorientation -Dementia -Depression |
| Environmental factors that may contribute to a Client Falling | -Room clutter -Poor lighting -Slippery floors |
| Other factors that may contribute to a Client Falling | -The use of certain medications—such as antidepressant, antihypertensive, and anticonvulsant drugs—that have a strong correlation with client falls -Age -Bathroom frequency, with or without incontinence -The staffing levels on the unit |
| Fall Safety Champions | The champions are fall safety experts within the facility that promote strategies aimed at fall prevention. |
| Universal Fall Precautions pt.1 | -Use of non-skid footwear -Keeping the bed in the low position -Locking the wheels of beds -Placing the brakes on wheelchairs |
| Universal Fall Precautions pt.2 | -Maintaining a clutter-free environment -Adequate lighting -Placing the call light and belongings within clients’ reach -Fall prevention education for clients, along with basic orientation to the room and call light system |
| Movement Alarms | A fall prevention tool that can attach to the bed, chair, or person. The alarm will ring when the client attempts to move from their current environment. |
| Restraints | Used to decrease the client’s movement and function for their safety as well as other clients and staff. There are five types of restraints that include physical, mechanical, chemical, barrier, and seclusion. |
| Physical Restraint | The manual holding or immobilizing the client using physical strength. |
| Mechanical Restraint | A physical device that is applied to a person to restrict their movement. It may consist of the use of materials such as straps, fabric, leather devices that can fasten around the client's wrists or ankles. |
| Chemical Restraint | The administration of medications (including benzodiazepines, antipsychotics, and neuromuscular blocking agents) to reduce the client's movement or control behavior. |
| Barrier Restraint | Restrain a client’s movement within a setting through the use of barriers to limit movement such as concave mattresses and lapboards that are attached to chairs. |
| Seclusion | Placing the client alone in a securely locked room. |
| Hoyer Lift | A device with locking wheels that is used to lift clients out of bed or chair. It has a sling to cradle clients. |
| Ceiling Lift | They are lifts mounted in the ceiling that are used to lift and transfer clients in and out of bed or the chair. It has a sling to cradle clients. |
| PolyGlide Sheet | A smaller version of the turnsheet or glide sheet. They are meant for movement of body parts as in an obese client’s extremities. |
| Sit-to-Stand Lift | A mobile lift, with locking breaks, that takes the client from a sitting to standing position. |
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