Chapter 13: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care
Thoughtful practice is nursing practice that is considerate and compassionate. A thoughtful
nurse always keeps the person at the center of caregiving in order to promote the humanity,
dignity, and well-being of the patient.
Person-centered care means doctors and other health care providers work collaboratively with
patients and other health care providers to do what is best for the patients’ health and
well-being.
Therapeutic relationship --When the relationship between the caregiver and the person who is
being cared for is focused on promoting or restoring the health and well-being of the person
being cared for in the relationship or facilitating their dying with respect and comfort, it
becomes a therapeutic relationship.
Caring is the human mode of being. Caring is the essence of nursing and the moral imperative
that guides nursing praxis (education, practice, and research). Caring is both spiritual and human
consciousness that connects and transforms everything in the universe.
Blended competencies --To do this successfully, nurses need many cognitive, technical,
interpersonal, and ethical/legal competencies, along with the willingness to use them creatively
and critically when working with patients to promote or restore health, to prevent disease or
illness, and to facilitate coping with altered functioning. Blended competencies because, in most
instances, nursing actions require all four competencies.
Critical thinking is defined as “a systematic way to form and shape one’s thinking. It functions
purposefully and exactingly. It is thought that is disciplined, comprehensive, based on
intellectual standards, and, as a result, well-reasoned”.
Standards for critical thinking: clear, precise, specific, accurate, relevant, plausible, consistent,
logical, deep, broad, complete, significant, adequate (for the purpose), and fair.
Critical-thinking indicators(CTIs)-- are evidence-based descriptions of behaviors that
demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical
practice.
QSEN (Quality and Safety Education for Nurses) project--The overall goal of this is to meet the
challenge of preparing future nurses who will have the knowledge, skills, and attitudes (KSAs)
necessary to continuously improve the quality and safety of the health care systems within
which they work.
Clinical reasoning and decision making—specific terms—refer to the process you use to think
about patient problems in the clinical setting—for example, deciding how to prevent and
manage mobility issues. For reasoning about other clinical issues (e.g., teamwork, collaboration,
and streamlining workflow), nurses usually use critical thinking.
Clinical judgment refers to the result (outcome) of critical thinking, clinical reasoning, and
decision-making—the conclusion, decision, or opinion you make after analyzing information.
Trial-and-error problem solving involves testing any number of solutions until one is found that
works for that particular problem. This method is not efficient for the nurse and can be
dangerous to the patient; it is therefore not recommended as a guide for nursing practice.
Scientific problem solving is a systematic, seven-step problem-solving process that involves: (1)
problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5)
hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in a conclusion or
revision of the hypothesis. This method is used most commonly in a controlled laboratory setting
but is closely related to the more general problem-solving processes commonly used by health
care professionals as they work with patients. The nursing process is an example of this type of
problem-solving process.
Intuitive problem solving-- is thus a direct understanding of a situation based on a background
of experience, knowledge, and skill that makes expert decision making possible. A recovery
room nurse who realizes that a postoperative patient is deteriorating before there are
measurable signs to suggest trouble is using intuitive problem solving, as is an oncology nurse
who somehow senses the right moment to teach, offer encouragement, affirm, or simply listen.
Creative thinking -- Critical thinking and clinical reasoning also involve reflection and creative
thinking. Creative thinking involves imagination, intuition, and spontaneity, factors that underpin
the art of nursing. Creative thinking is brought into play when you ask “why” or “what if”
questions and is most useful when conventional solutions have not resolved a situation.
Nursing process is a systematic method that directs the nurse, with the patient’s participation,
to accomplish the following: (1) assess the patient to determine the need for nursing care, (2)
determine nursing diagnoses for actual and potential health problems and needs, (3) identify
expected outcomes and plan care, (4) implement the care, and (5) evaluate the results. The
phases in this person-centered, outcome-oriented process are interrelated; each phase depends
on the accuracy of the steps preceding it.
Concept mapping is an instructional strategy in which learners identify, graphically display in a
diagram or drawing, and identify interrelationships between core concepts.
Reflective practice is a purposeful activity that leads to action, improvement of practice, and
better patient outcomes. It is about looking at an event, understanding it, and learning from it.
Chapter 14: Clinical Judgment
Critical thinking-- is the intellectually disciplined process of actively and skillfully conceptualizing,
applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by,
observation, experience, reflection, reasoning, or communication, as a guide to belief and
action.
clinical reasoning--thought processes that allow healthcare providers to arrive at a conclusion.
Clinical judgment is the result or observed outcome of critical thinking and decision making.
AACN (2021) defines clinical judgment as “the skill of recognizing cues regarding a clinical
situation, generating and weighing hypotheses, taking action, and evaluating outcomes for the
purpose of arriving at a satisfactory clinical outcome”.
Situational awareness (SA), also referred to as situation awareness, is “the perception of the
elements in the environment in a volume of time and space, the comprehension of their
meaning and the projection of their status in the near future”.
Cognitive load is a term used to reference the amount of information a person can hold in their
memory at one time. Although related to multitasking, the reprioritization and refocusing nurses
do on an ongoing basis is unique and mentally taxing, which is why factors such as patient acuity
and staffing levels are important to consider.
Competency-- an expected level of performance that integrates knowledge, skills, abilities, and
judgment.
Chapter 15: Assessing
Assessing is the systematic and continuous collection, analysis, validation, and communication
of patient data, or information.
Data reflect how health functioning is enhanced by health promotion or compromised by illness
and injury.
Database includes all the pertinent patient information collected by the nurse and other health
care professionals. The database enables you to partner with patients to develop a
comprehensive and effective care plan.
Nursing history --During the assessment step of the nursing process, the nurse establishes the
database by interviewing the patient to obtain a nursing history. The nursing history identifies
the patient’s health status, strengths, actual and potential health problems, health risks, and
need for nursing care.
Initial assessment is performed shortly after the patient is admitted to a health care facility or
service.
Focused assessment--the nurse gathers data about a specific problem that has already been
identified.
Quick priority assessments (QPAs) are short, focused, prioritized assessments you do to gain the
most important information you need to have first. They are important because they can “flag”
existing problems and risks.
Emergency assessment When a patient presents with a physiologic or psychological crisis, the
nurse performs an emergency assessment to identify life-threatening problems.
Time-lapsed assessment is scheduled to compare a patient’s current status to the baseline data
obtained earlier. Most patients in residential settings and those receiving nursing care over
longer periods of time, such as homebound patients with visiting nurses, are scheduled for
periodic time-lapsed assessments to reassess their health status and to make necessary
revisions in the care plan. This assessment can be comprehensive or focused.
Triage-- Many nurses serve as triage professionals who screen patients to determine the extent
and severity of the their problems and then recommend appropriate follow-up. A triage nurse
working for an internal medicine practice in a university hospital will take phone calls from
patients without appointments experiencing distressing symptoms such as shortness of breath,
pressure or tightness in the chest, or increases in temperature.
Patient-Centered Assessment Method (PCAM) is a tool health care practitioners can use to
assess patient complexity using the social determinants of health (see Chapter 3); these
determinants may explain why some patients engage and respond well in managing their health
while others with the same or similar health conditions do not experience the same outcomes.
Minimum data set-- most schools of nursing and health care institutions have a minimum data
set that specifies the information that must be collected from every patient and uses a
structured assessment form to organize or cluster this data.
There are two types of data: subjective and objective.
Subjective data are information perceived only by the affected person; these data cannot be
perceived or verified by another person. Examples of subjective data are feeling nervous,
nauseated, or chilly, and experiencing pain. Subjective data also are called symptoms or covert
data.
Objective data are observable and measurable data that can be seen, heard, felt, or measured
by someone other than the person experiencing them. Objective data observed by one person
can be verified by another person observing the same patient. Examples of objective data are an
elevated temperature reading (e.g., 101°F), skin that is moist, and refusal to look at or eat food.
Objective data also are called signs or overt data.
Observation is the conscious and deliberate use of the five senses to gather data. Skilled nurses
observe and interpret meaningful stimuli (data) in each nurse–patient interaction.
Interview --You obtain the nursing history by interviewing the patient. An interview is a planned
communication.
Physical assessment is the examination of the patient for objective data that may better define
the patient’s condition and help the nurse plan care.
Review of systems(ROS)-- the nursing physical assessment involves the examination of all body
systems in a systematic manner, commonly using a head-to-toe format; this is called the review
of systems (ROS). Four methods are used to collect data during the physical assessment:

Inspection: the process of performing deliberate, purposeful observations in a systematic
manner

Palpation: use of the sense of touch to assess skin temperature, turgor, texture, and
moisture as well as vibrations within the body

Percussion: the act of striking one object against another to produce sound

Auscultation: the act of listening with a stethoscope to sounds produced within the body
Cue--Nurses now use the language of cues and inferences to describe the early analysis of data.
The subjective and objective data you identify (“the patient does not respond when I speak to
him on his left side”) is a cue that something may be wrong.
Inference-- The judgment you reach about the cue (the patient’s hearing may be impaired on his
left side) is an inference.
Validation is the act of confirming or verifying. The purpose of validating is to keep data as free
from error, bias, and misinterpretation as possible.
Chapter 16: Diagnosis/Problem Identification
Diagnosing/analyzing--diagnosing Problem identification—the second step/phase in the nursing
process—begins after the nurse has collected and recorded the patient data. The purposes of
diagnosing/analyzing are to (1) identify how a person, group, or community responds to actual
or potential health and life processes; (2) identify factors that contribute to or cause health
problems (etiologies); and (3) identify resources or strengths that the person, group, or
community can draw on to prevent or resolve problems.
Health problem is a condition that necessitates intervention to prevent or resolve disease or
illness or to promote coping and wellness.
Cue-- Most experienced nurses begin the work of interpreting and analyzing data while they are
still collecting (assessing) the data. The term cue is often used to denote significant data or data
that influence this analysis.
Nursing diagnoses-- When a health problem is identified, the nurse must decide which health
care professional-- can best address the problem. Actual or potential health problems that can
be prevented or resolved by independent nursing intervention have historically been termed
nursing diagnoses.
Medical diagnoses identify diseases, whereas problem statements focus on unhealthy responses
to health and illness. Medical diagnoses describe problems for which the physician or advanced
practice nurse directs the primary treatment.
Diagnostic error-- Sorting out healthy patient responses from those that are not healthy is not as
clear-cut as it may seem. To avoid erroneously labeling selected patient health patterns as
unhealthy (diagnostic error) while failing to detect an actual unhealthy behavior, nurses must be
familiar with comparative standards to be used in data interpretation and analysis.
Standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can
be compared in the same class or category.
Data cluster is a grouping of patient data or cues that point to the existence of a health problem.
Problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human
response to a health condition/life process that exists in an individual, family, group, or
community.
Risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family,
group, or community for developing an undesirable human response to health conditions/life
processes.
Health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to
increase well-being and to actualize human health potential. These responses are expressed by a
readiness to enhance specific health behaviors and can be used in any health state. Health
promotion responses may exist in an individual, family, group, or community.
Chapter 17: Outcome Identification and Planning
During the outcome identification and planning phase of the nursing process, the nurse works
in partnership with the patient and family to:

Establish priorities

Identify and write expected patient outcomes

Select evidence-based nursing interventions

Communicate the nursing plan of care
A goal is an aim or an end. A patient outcome is an expected conclusion to a patient health
problem, or in the event of a wellness diagnosis, an expected conclusion to a patient’s health
expectation. The words goal, objective, and outcome are often used interchangeably. In some
practice settings, the term goal or objective is used to describe what is wanted, and the term
outcome is used to describe the results achieved.
Expected outcomes is used to refer to the more specific, measurable criteria used to evaluate
the extent to which a goal has been met.
Initial planning is performed by the nurse with the admission nursing history and the physical
assessment. This comprehensive plan addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related nursing care.
Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes,
and related nursing interventions common to a specific population or health problem.
Ongoing planning is carried out by any nurse who interacts with the patient. Its chief purpose is
to keep the plan up to date to facilitate the resolution of health problems, manage risk factors,
and promote function.
Discharge planning is best carried out by the nurse who has worked most closely with the
patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge
of existing community resources.
Maslow’s Hierarchy of Human Needs
Because basic needs must be met before a person can focus on higher ones, patient needs may
be prioritized according to the following hierarchy:
1. Physiologic needs
2. Safety needs
3. Love and belonging needs
4. Self-esteem needs
5. Self-actualization needs
Nursing Outcomes Classification (NOC) developed by the Iowa Outcomes Project presents the
first comprehensive standardized language used to describe the patient outcomes that are
responsive to nursing intervention. The current classification lists 490 outcomes with definitions,
indicators, measurement scales, and supporting references. A memory jog for writing goals and
outcomes is the word SMART (Doran, 1981):
S—specific, M—measurable, A—attainable, R—realistic, T—time-bound
Nursing Interventions Classification (NIC) project defines a nursing intervention as “any
treatment based upon clinical judgment and knowledge that a nurse performs to enhance
patient/client outcomes”.
Nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse
executes to benefit the patient in a predictable way related to the nursing diagnosis and
projected outcomes.
Physician-initiated interventions --An intervention is initiated by a physician in response to a
medical diagnosis but is carried out by a nurse in response to a doctor’s order. For example, a
physician examining a patient brought into the emergency department after a motor vehicle
accident might ask the nurse to administer a medication to relieve pain and to schedule the
patient for radiographs and other diagnostic tests. The nurse who performs these interventions
is implementing physician-initiated interventions.
Collaborative interventions --Nurses also carry out treatments initiated by other providers such
as pharmacists, respiratory therapists, or physician assistants; these are collaborative
interventions.
Consultation, a process in which two or more people with varying degrees of experience and
expertise discuss a problem and its solution, often proves helpful.
Nursing care plan (patient care plan) is the written guide that directs the efforts of the nursing
team working with the patient to meet their health goals. It specifies nursing
diagnoses/problems, outcomes, and associated nursing interventions.
Computerized nursing care plans --Nurses now often use computerized nursing care plans as
part of the electronic medical record. The benefits of computerized plans include ready access to
a large knowledge base; improved record keeping and a resulting improvement in audits and
quality assurance; documentation by all members of the health care team with printouts for the
patient’s record and for change-of-shift reports; and less time spent on paperwork.
Clinical pathways (critical pathways, CareMaps) are tools used in case management to
communicate the standardized, interdisciplinary care plan for patients.
Chapter 18: Implementing
Implementing phase of the nursing process, the evidence-based nursing actions planned in the
previous step are carried out. The purpose of implementation is to help the patient achieve
valued health outcomes: promote health, prevent disease and illness, restore health, and
facilitate coping with altered functioning.
Scope of practice describes the services that a qualified health professional is deemed
competent to perform and permitted to undertake—in keeping with the terms of their
professional license. The ANA states that the Nursing: Scope and Standards of Practice describes
the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice:
Who: Registered Nurses (RN) and Advanced Practice Registered Nurses (APRN) comprise the
“who” constituency and have been educated, titled, and maintain active licensure to practice
nursing.

What: Nursing is the protection, promotion, and optimization of health and abilities;
prevention of illness and injury; facilitation of healing; alleviation of suffering through the
diagnosis and treatment of human response; and advocacy in the care of individuals,
families, groups, communities, and populations.

Where: Where there is a patient in need of care.

When: Whenever there is a need for nursing knowledge, compassion, and expertise.

Why: The profession exists to achieve the most positive patient outcome in keeping with
nursing’s social contract and obligation to society
Clinical inquiry is defined as the ongoing process of questioning and evaluating practice and
advancing informed practice.
Nursing intervention as “any treatment based upon clinical judgment and knowledge that a
nurse performs to enhance patient/client outcomes”. TYPES OF NURSING INTERVENTIONS:
Direct care intervention is a treatment performed through interaction with the patient(s). Direct
care interventions include both physiologic and psychosocial nursing actions and include both
the “laying on of hands” actions and those that are more supportive and counseling in nature.
Indirect care intervention is a treatment performed away from the patient but on behalf of a
patient or group of patients. Indirect care interventions include nursing actions aimed at
management of the patient care environment and interdisciplinary collaboration. These actions
support the effectiveness of direct care interventions.
Protocols are written plans that detail the nursing activities to be executed in specific situations.
Although some protocols specify routine aspects of nursing care (e.g., protocols that describe
nursing responsibilities when a patient is admitted to or discharged from the institution), other
protocols include standing orders that empower the nurse to initiate actions that ordinarily
require the order or supervision of a health care provider.
Standing orders are written protocols that authorize designated members of the health care
team (e.g., nurses or medical assistants) to complete certain clinical tasks without having to first
obtain a physician order.
Care bundle --a structured way of improving processes of care and patient outcomes: A small
straightforward set of evidence-based practices—generally three to five—that, when performed
collectively and reliably, have been proven to improve patient outcomes.
Evidence-based practice in nursing involves providing holistic, quality care based on the most
up-to-date research and knowledge rather than traditional methods, advice from colleagues, or
personal beliefs.
Adverse reaction is an unwanted or harmful reaction experienced following the administration
of a drug, diagnostic test, or therapeutic intervention under normal conditions of use.
Delegation is the transfer of responsibility for the performance of an activity to another person
while retaining accountability for the outcome.
Chapter 19: Evaluating
Evaluating --the fifth phase of the nursing process, the nurse and patient together measure how
well the patient has achieved the outcomes specified in the care plan. When evaluating patient
outcome achievement, the nurse identifies factors that contribute to the patient’s ability to
achieve expected outcomes and, when necessary, modifies the plan of care.

The purpose of evaluation is to allow the patient’s achievement of expected outcomes to
direct future nurse–patient interactions. Based on the patient’s responses to the plan of
care, the nurse decides to: Terminate(succussed), Modify, Continue the plan.
Criteria are measurable qualities, attributes, or characteristics that identify skills, knowledge, or
health states.
Standards are the levels of performance accepted by and expected of nursing staff or other
health team members. They are established by authority, custom, or consent. A good example of
standards is the American Nurses Association’s (ANA’s) Nursing: Scope and Standards of Practice.
Evaluative statement --After the data have been collected and interpreted to determine patient
outcome achievement, the nurse makes and documents a judgment summarizing the findings.
This is termed the evaluative statement. The two-part evaluative statement includes a decision
about how well the outcome was met, along with patient data or behaviors that support this
decision. Outcomes may have been met, partially met, or not met:
Performance improvement-- Nurses committed to healthier patients, quality care, reduced
costs, and the personal satisfaction of knowing that they are actually making a difference versus
merely wishing things were different value performance improvement. The following four steps
are crucial in improving performance:
1. Discover a problem
2. Plan a strategy using indicators
3. Implement a change
4. Assess the change; if the outcome is not met, plan a new strategy
Peer review, the evaluation of one staff member by another staff member on the same level in
the hierarchy of the organization, is an important mechanism nurses can use to improve their
professional performance.
Quality-assurance programs are special programs that promote excellence in nursing. These
range from small programs conducted by nurses on a nursing unit to those developed for an
entire institution, state, or country.
Structure evaluation or audit focuses on the environment in which care is provided. Standards
describe physical facilities and equipment; organizational characteristics, policies, and
procedures; fiscal resources; and personnel resources.
Process evaluation focuses the nature and sequence of activities carried out by nurses
implementing the nursing process. Criteria make explicit acceptable levels of performance for
nursing actions related to patient assessment, diagnosis, planning, implementation, and
evaluation.
Outcome evaluation focuses on measurable changes in the health status of the patient, or the
end results of nursing care. While the proper environment for care and the right nursing actions
are important aspects of quality care, the critical element in evaluating care is demonstrable
changes in patient health status.
Quality improvement (QI)—also known as continuous quality improvement (CQI) or total
quality management (TQM)—consists of systematic and continuous actions that lead to
measurable improvement in health care services and the health status of targeted patient
groups.
Nursing-sensitive quality indicators --are indicators specific to nursing that identify structures of
care and care processes that influence care outcome. Examples of nursing-sensitive quality
indicators for acute care settings are the mix of RNs, LPNs, and unlicensed staff caring for
patients, the total number of nursing care hours provided per patient day, and the rates of
pressure injuries and patient falls.
National Database of Nursing Quality Indicators (NDNQI) --The goals are to promote and
facilitate the standardization of information submitted by hospitals across the United States on
nursing quality and patient outcomes.
Concurrent evaluation is conducted by using direct observation of nursing care, patient
interviews, and chart review to determine whether the specified evaluative criteria are met.
Retrospective evaluation may use post discharge questionnaires, patient interviews (by
telephone or face to face), or chart review (nursing audit) to collect data.
Chapter 20: Documenting and Reporting
Documentation is the written or electronic legal record of all pertinent interactions with the
patient: assessing, diagnosing, planning, implementing, and evaluating.
Patient record is a compilation of a patient’s health information (PHI).
Read-back: Verbal orders (VOs) must be given directly by the physician or nurse practitioner to a
registered professional nurse or registered professional pharmacist, who receives, reads back,
documents and executes the order. In “read-back,” the recipient reads back the message as they
heard and interpreted it.
Electronic health records (EHRs), or computer-based records--data can be distributed among
many caregivers in a standardized format, allowing them to compare and uniformly evaluate
patient progress easily.
Health information exchange (HIE): An HIE is an organization that provides services to enable
the electronic sharing of health-related information. allows physicians, nurse practitioners,
physician assistants, nurses, pharmacists, other health care providers, and patients to
appropriately access and securely share a patient’s vital medical information electronically,
improving the speed, quality, safety, and cost of patient care.
Source-oriented record is a paper format in which each health care group keeps data on its own
separate form. Sections of the record are designated for nurses, health care providers, laboratory,
x-ray personnel, and so on.
Progress notes--Notes written to inform caregivers of the progress a patient is making toward
achieving expected outcomes are called progress notes. Progress notes written by nurses in a
source-oriented record are narrative notes and address routine care, patient data, and patient
problems identified in the care plan. They include a description of the status of the problem,
related nursing interventions, patient responses to interventions, and needed revisions to the
care plan.
Problem-oriented medical record (POMR), or problem-oriented record-- is organized around a
patient’s problems rather than around sources of information.
SOAP format-- (Subjective data, Objective data, Assessment [the caregiver’s judgment about the
situation], Plan) is used to organize entries in the progress notes of the POMR.
PIE charting system is unique in that it does not develop a separate care plan. The care plan is
incorporated into the progress notes, which identify problems by number (in the order they are
identified).
Focus charting-- The purpose of focus charting is to bring the focus of care back to the patient
and the patient’s concerns. Instead of a problem list or list of nursing or medical diagnoses, a
focus column is used that incorporates many aspects of a patient and patient care. The focus
may be a patient strength, problem, or need.
Charting by exception (CBE) is a shorthand method of documenting normal findings, based on
standardized normals, standards of practice, and predetermined criteria for assessments and
interventions. Significant findings or exceptions to the predefined norms are only documented
in detail.
Collaborative pathways—also called critical pathways or care maps—are used in the case
management model. The collaborative pathway specifies the care plan linked to expected
outcomes along a timeline. In some documentation systems, the collaborative pathway is part of
a computerized documentation system that integrates the collaborative pathway and
documentation flow sheets designed to match each day’s expected outcomes. CBE is frequently
used with collaborative pathway documentation systems.
Occurrence charting or variance charting-- The usual format for occurrence charting or variance
charting is the unexpected event, the cause of the event, actions taken in response to the event,
and discharge planning, when appropriate. The variances most likely to be documented are
those that affect quality, cost, or length of stay.
Flow sheets are documentation tools used to efficiently record routine aspects of nursing care.
Well-designed flow sheets enable nurses to quickly document the routine aspects of care that
promote patient goal achievement, safety, and well-being. Ex: I &O
Graphic record is a form used to record specific patient variables such as pulse, respiratory rate,
blood pressure readings, body temperature, weight, fluid intake and output, bowel movements,
and other patient characteristics.
Outcome and Assessment Information Set (OASIS) is a group of data elements that: represent
core items of a comprehensive assessment for an adult home care patient. form the basis for
measuring patient outcomes for purposes of outcome-based quality improvement (OBQI).
Minimum data set: A core set of screening, clinical, and functional status elements that form the
foundation of the comprehensive assessment of all residents in long-term care facilities certified
to participate in Medicare or Medicaid. The items in the minimum data set standardize
communication about resident problems and condition.
Change-of-shift report or handoff is given by a primary nurse to the nurse replacing them, or by
the charge nurse to the nurse who assumes responsibility for continuing care of the patient. The
change-of-shift report may be given in written form or orally in a meeting, or it may be audio- or
videotaped.
Bedside report --The trend today is toward a standardized, streamlined shift report system at
the bedside. Vital elements of the bedside report include the oncoming and outgoing nurse
assessing the patient together, reviewing medication records and the health care provider’s and
nursing orders, and establishing patient goals for the shift.
Incident report, also termed a variance report or occurrence report, is a tool used by health
care facilities to document unexpected events that result in, or have the potential to result in,
harm to a patient or person or damage property. An incident report should be filed whenever an
unexpected event occurs.
Confer is to consult with someone to exchange ideas or to seek information, advice, or
instructions.
Consultation --The process of inviting another professional to evaluate the patient and make
recommendations to you about the patient’s treatment is called a consultation.
Referral-- The process of sending or guiding the patient to another source for assistance is called
a referral.
Purposeful rounding is a proactive, systematic, nurse-driven, evidence-based intervention that
helps nurses anticipate and address patient needs.
Discharge summary--When a patient is discharged from care or transferred from one unit,
institution, or facility to another, a discharge summary should be written that concisely
summarizes the reason for treatment, significant findings, the procedures performed and
treatment rendered, the patient’s condition on discharge or transfer, and any specific pertinent
instructions given to the patient and family.
Chapter 32: Hygiene
Personal hygiene--Measures for maintaining a minimal level of personal cleanliness and
grooming, called personal hygiene, promote physical and psychological well-being.
Caries --The decay of teeth with the formation of cavities is called caries. Caries result from
failure to remove plaque.
Plaque --an invisible, destructive, bacterial film that builds up on everyone’s teeth and
eventually leads to the destruction of tooth enamel. A successful plaque-fighting program
includes limiting sweet snacks such as soft drinks, candy, gum, jams, and jellies between meals;
thorough cleansing of the teeth; and regular dental checkups. The use of antiplaque fluoride
toothpastes, mouth rinses, and flossing also help prevent dental caries.
Gingivitis is an inflammation of the gingiva, the tissue that surrounds the teeth.
Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves
degeneration of the dental periosteum (tissues) and bone. Symptoms include bleeding gums;
swollen, red, painful gum tissues; receding gum lines with the formation of pockets between the
teeth and gums; pus that appears when gums are pressed; and loose teeth.
Tartar --If unchecked, plaque builds up and, along with dead bacteria, forms hard deposits called
tartar at the gum lines. The tartar attacks the fibers that fasten teeth to the gums and eventually
attacks bone tissue. The teeth then loosen and fall out.
Halitosis, a strong mouth odor or a persistent bad taste in the mouth, may be the first indication
of periodontal disease. Regular treatment by a dentist is imperative.
Stomatitis, an inflammation of the oral mucosa, has numerous causes, such as bacteria, virus,
mechanical trauma, irritants, nutritional deficiencies, and systemic infection. Symptoms may
include heat, pain, increased flow of saliva, and halitosis.
Glossitis, an inflammation of the tongue, can be caused by deficiencies of vitamin B12, folic acid,
and iron.
Cheilosis, an ulceration and dry scaling of the lips with fissures at the angles of the mouth, can
have multiple causes, including infections of the oral cavity (e.g., strep bacteria), a lack of iron or
B vitamin deficiencies (especially riboflavin), and skin irritation (e.g., eczema).
Cerumen –Pay particular attention to a buildup of cerumen (wax) in the canal, dryness, crusting,
or the presence of any discharge or foreign body. Older adults can have a buildup of cerumen
that can cause impaired hearing.
Alopecia --Hair growth and hair loss are ongoing, daily processes. Hair loss becomes a potential
problem only when it exceeds hair growth. Absence or loss of hair is called alopecia. Alopecia
on the head is also referred to as baldness. Alopecia can be a partial or complete, local or
generalized, loss of hair. Patchy hair loss can result from infections of the scalp. Hair loss from
plaiting, excessive backcombing and teasing, or the use of hair rollers is usually temporary;
hair returns when the tension on the hair shaft is halted.
Pediculosis --Infestation with lice.
Chapter 33: Skin Integrity and Wound Care
Epidermis --The top layer, or outermost portion. The epidermis is composed of layers of
stratified epithelial cells. These cells fuse to form a protective, waterproof layer of keratin
material. Epithelial cells have no blood vessels of their own and depend on underlying tissues for
nourishment and waste removal. When well nourished, epithelium regenerates relatively easily
and quickly.
Dermis ---The second layer of skin, consists of a framework of elastic connective tissue
comprised primarily of collagen. Nerves, hair follicles, glands, immune cells, and blood vessels
are located in this layer (Norris, 2019). Each hair consists of the shaft, which projects through the
dermis beyond the surface of the skin, and the hair follicle, which lies in the dermis.
Subcutaneous tissue --the bottom layer that anchors the skin layers to the underlying tissues of
the body. The subcutaneous tissue consists of adipose tissue, made up of lobules of fat cells, and
connective tissue. This layer stores fat for energy, serves as a heat insulator for the body, and
provides a cushioning effect for protection. This fatty tissue layer contains blood and lymph
vessels, nerves, and fat cells.
Wound is a break or disruption in the normal integrity of the skin and tissues.
Exudate –(After a brief period of constriction during homeostasis) the blood vessels dilate and
capillary permeability increases, allowing plasma and blood components to leak out into the
area that is injured, forming a liquid called exudate. Ex: Serosanguinous exudate.
Granulation tissue --The new tissue forms the foundation for scar tissue development. It is
highly vascular, red, and bleeds easily.
Scar (avascular collagen tissue that does not sweat, grow hair, or tan in sunlight) eventually
becomes a flat, thin line. Scar tissue is less elastic than uninjured tissue. The strength of the scar
tissue remains less (70% to 80%) than that of normal tissue, even many years following injury,
and it is never fully restored. Wounds that heal by secondary intention take longer to remodel
and form a scar smaller than the original wound.
A variety of factors affect wound healing. Local factors, those occurring directly in the wound,
include pressure, desiccation (dehydration), maceration (overhydration), trauma, edema,
infection, excessive bleeding, necrosis (death of tissue), and the presence of biofilm (a thick
grouping of microorganisms).
Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick,
self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased
effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the
effectiveness of the normal immune response by the patient.
Epithelialization --epithelial cells form a new surface layer.
Eschar --Dead tissue present in the wound delays healing. Dead tissue appears as slough—moist,
yellow, stringy tissue—and eschar appears as dry, black, leathery tissue.
Hematoma --Internal hemorrhage causes the formation of a hematoma, a localized mass of
usually clotted blood.
Dehiscence and evisceration are the most serious postoperative wound complications.
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Dehiscence is the partial or total separation of wound layers as a result of excessive stress
on wounds that are not healed.
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Evisceration is the most serious complication of dehiscence. It occurs primarily with
abdominal incisions. In evisceration, the abdominal wound completely separates, with
protrusion of viscera (internal organs) through the incisional area.
Fistula is an abnormal passage from an internal organ or vessel to the outside of the body, or
from one internal organ or vessel to another. Fistulas may be created purposefully; for example,
an arteriovenous (AV) fistula is created surgically to provide circulatory access for kidney dialysis.
Abscess --However, fistula formation is often the result of infection that has developed into an
abscess, which is a collection of infected fluid that has not drained. Accumulated fluid applies
pressure to surrounding tissues, leading to the formation of the unnatural passage between two
visceral organs or an organ and the skin.
Pressure injury is defined as localized damage to the skin and underlying tissue that usually
occurs over a bony prominence or is related to the use of a (medical or other) device. The
National Pressure Injury Advisory Panel recently updated their staging definitions, and the term
Pressure ulcer was replaced by pressure injury to better-represent the early stages of pressure
injury where there is not an actual ulcer or break in the skin. A pressure injury may be acute or
chronic.
Ischemia--deficiency of blood in a particular area.
Hypoxia --inadequate amount of oxygen available to cells.
Friction occurs when two surfaces rub against each other. The injury, which resembles an
abrasion, can also damage superficial blood vessels directly under the skin. A patient who lies on
wrinkled sheets is likely to sustain tissue damage as a result of friction.
Shear results when one layer of tissue slides over another layer. Shear separates the skin from
underlying tissues. Shear includes shear stress, the force, and shear strain, the “distortion or
deformation of tissue” (NPIAP, 2019, p. 5) secondary to shear stress. The small blood vessels and
capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the
tissue cells under the skin.
Erythema--redness in lightly pigmented skin.
DRAINAGE--The inflammatory response results in the formation of exudate which then drains
from the wound. The exudate may contain fluid/serum, cellular debris, bacteria, and leukocytes.
This exudate is called wound drainage and is described as serous, sanguineous, serosanguineous,
or, if infected, purulent.
• Serous drainage is composed primarily of the clear, serous portion of the blood and from
serous membranes. Serous drainage is clear and watery.
• Sanguineous drainage consists of large numbers of red blood cells and looks like blood.
Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage
indicates older bleeding.
• Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood
tinged.
• Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead
and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color
(such as dark yellow or green), depending on the causative organism.
Presence of any abnormal pathways in the wound, such as a sinus tract (a cavity or channel
underneath the wound that has the potential for infection) or tunneling (a passageway or
opening that may be visible at skin level, but with most of the tunnel under the surface of the
skin).
Dressing --protective coveringplaced over a wound.
Debridement --removal of devitalized tissue and foreign material.
Bandages are strips of cloth, gauze (e.g., roller gauze, Kerlix, Kling), or elasticized material (e.g.,
ACE bandages) used to wrap a body part.
Negative pressure wound therapy (NPWT) promotes wound healing and wound closure
through the application of uniform negative pressure on the wound bed, reduction in bacteria
in the wound, and the removal of excess wound fluid, while providing a moist wound healing
environment.
Vasoconstriction --the constriction of blood vessels, which increases blood pressure.
Vasodilation --the dilatation of blood vessels, which decreases blood pressure.