Fundamentals terms

36 terms

Active listening: Giving full attention to a speaker to understand both their words and their feelings. It includes facing the client, appropriate eye contact, nodding and brief prompts such as "go on", allowing silence, and then paraphrasing, reflecting feelings, clarifying and summarizing. Active listening shows respect and helps the nurse collect accurate assessment data.
Assertive communication: Stating needs, opinions and limits clearly, honestly and directly while respecting the rights of others. In passive communication, people hide their own needs to avoid conflict; in aggressive communication, they disregard or attack others. Assertiveness lets a nurse speak up for patient safety, for example by voicing a concern with structured statements such as CUS.
Blood pressure: The force of blood against arterial walls, measured in mmHg and written as systolic/diastolic. For an accurate reading, choose a cuff sized to the arm circumference, let the client rest for a few minutes and support the arm at heart level. A cuff that is too small reads falsely high; one that is too large reads falsely low.
Body mass index: A screening measure calculated as weight in kilograms divided by the square of height in meters (kg/m²). By WHO adult categories, below 18.5 is underweight, 18.5–24.9 normal, 25–29.9 overweight and 30 or above obesity. It does not reflect muscle mass or fat distribution, so pair it with waist circumference.
Body mechanics: Using the body efficiently and in balance while lifting, carrying and transferring clients, so the musculoskeletal system is protected. Key principles are a wide base of support, bending at the knees, keeping the load close and avoiding twisting. Use lift devices and enough staff for safe patient handling.
Braden Scale: A tool that predicts pressure-injury risk across six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Totals range from 6 to 23; the lower the score, the higher the risk, with 18 or below generally indicating risk. Score on admission and whenever the condition changes, and plan prevention from the result.
Empathy: Understanding a person's feelings and experience from their point of view and conveying that understanding back, while keeping one's own perspective ("It sounds frightening to wait for the results"). Sympathy is sharing the feeling or feeling sorry for the person, which can shift the focus to the nurse. Empathy builds trust, helps clients express feelings and is the basis of the therapeutic relationship.
Enteral nutrition: Feeding through a nasogastric, nasoenteric, gastrostomy (PEG) or jejunostomy tube for a client whose gut works but who cannot eat enough by mouth. To prevent aspiration, keep the head of the bed raised at least 30° (preferably 30–45°) during and after feeding, verify tube placement, and flush the tube with water after each medication and feeding.
Fall risk assessment: Scoring a client's likelihood of falling with a validated tool on admission, after any change in condition and at regular intervals. In Türkiye the Ministry of Health publishes the Itaki scale for adults and the Harizmi scale for children, and institutions may use other validated tools such as the Morse Fall Scale. Previous falls, gait problems, sedating drugs and confusion raise the risk. Core precautions: bed low and locked, call light within reach, nonslip footwear and good lighting.
Fever: A body temperature above normal caused by a raised hypothalamic set point; in adults 38 °C (100.4 °F) or higher is generally treated as fever. It is most often a response to infection. Record the route of measurement, support fluid intake, watch for chills and dehydration, and report fever in a neutropenic client or a newborn at once.
Food safety: Practices in preparing, storing and eating food that prevent foodborne illness. WHO's Five Keys to Safer Food: keep clean, separate raw and cooked food, cook thoroughly, keep food at safe temperatures, and use safe water and raw materials. Pregnant women, infants, older adults and people with weakened immunity are most at risk. When two or more people fall ill from the same food, report a possible outbreak.
Fowler's position: A supine position with the head of the bed raised: semi-Fowler's 30–45°, Fowler's 45–60° and high Fowler's 60–90°. It eases breathing by letting the diaphragm descend and lowers aspiration risk, so it is used for dyspnea and tube feeding. Watch for sacral pressure when it is held for long periods.
I-message: A way of speaking that describes a behavior, its effect and one's feeling, then what one needs, without blaming: "When the handover is interrupted, I worry that I'll miss something; I'd like us to finish it first." A "you" message ("You always interrupt") sounds like an accusation and makes the other person defensive. I-messages keep communication open in conflict and when giving feedback.
Intake and output: Measuring and recording in mL everything a client takes in (oral, enteral, parenteral) and puts out (urine, vomit, drains, diarrhea) over a set period. It shows fluid balance in heart or kidney failure, during diuretic therapy and when dehydration is a risk, and is interpreted together with daily weights.
Intramuscular injection: Injecting a drug into deep muscle, usually at a 90° angle. In adults the ventrogluteal site is preferred because it lies away from major vessels and nerves; the deltoid is used for small-volume vaccines and the vastus lateralis in infants. The Z-track technique keeps irritating drugs from leaking into subcutaneous tissue.
Intravenous route: Giving a drug, fluid or blood product directly into a vein. Onset is immediate and bioavailability complete, but errors cannot be undone. Before each administration check that the catheter is patent and the drugs are compatible, and assess the site regularly for infiltration, phlebitis and infection.
Macronutrients: The nutrients the body needs in large amounts and that provide energy: carbohydrates (the main energy source), proteins (building and repairing tissue) and fats (energy storage and carrying fat-soluble vitamins). Carbohydrate and protein provide about 4 kcal per gram and fat about 9 kcal per gram. Assess the intake of each nutrient, not only total energy.
Malnutrition: Deficiency, excess or imbalance in a person's intake of energy and nutrients; WHO counts both undernutrition and overweight and obesity as malnutrition. In hospital, undernutrition delays wound healing and raises the risk of infection, pressure injuries, muscle loss and falls, and lengthens stays. Screen on admission with a validated tool such as NRS-2002, monitor weight and food intake, help with meals and refer clients at risk to the dietitian.
Micronutrients: The vitamins and minerals the body needs in small amounts. Vitamins A, D, E and K are fat-soluble and stored in the body, so an excess can build up; the B vitamins and vitamin C are water-soluble. Iron, iodine, calcium and zinc are key minerals. In Türkiye, the Ministry of Health gives vitamin D to infants and pregnant women and iron to pregnant women; deficiencies can cause fatigue, anemia and poor growth.
Nasogastric tube: A tube passed through the nose and esophagus into the stomach for feeding, medications or gastric decompression. Length is estimated from the tip of the nose to the earlobe to the xiphoid process. Initial placement is confirmed by X-ray; before each use check the external marking and the aspirate pH, and stop if the client develops respiratory distress.
Nonverbal communication: Communication beyond words: facial expression, eye contact, posture, gestures, touch, tone and pace of voice, silence and personal space. When words and nonverbal cues disagree, people usually believe the nonverbal ones. Meanings differ between cultures. Keep an open posture at eye level and notice cues such as a client grimacing while saying "I'm fine".
Nursing diagnosis: A nurse's clinical judgment about how a person, family or community responds to health problems or life processes. Unlike a medical diagnosis, it names the human response rather than the disease, and it guides interventions nurses carry out independently. It is often written in PES format: problem, etiology and signs/symptoms.
Nursing process: The systematic, client-centered problem-solving method nurses use to plan and deliver care. Its five steps are assessment, diagnosis, planning, implementation and evaluation (ADPIE). It is cyclical: evaluation findings feed back into a revised care plan.
Obesity: Excess fat accumulation that impairs health; WHO defines obesity in adults as a body mass index of 30 kg/m² or more. A large waist circumference shows abdominal obesity, which carries extra metabolic risk. Obesity raises the risk of type 2 diabetes, hypertension, cardiovascular disease, sleep apnea, osteoarthritis and some cancers. Discuss weight with respect and without blame, and support balanced eating and physical activity.
Orthostatic hypotension: A drop in systolic pressure of at least 20 mmHg, or in diastolic pressure of at least 10 mmHg, within 3 minutes of standing up from lying or sitting. Dizziness, light-headedness and fainting raise the risk of falls. Have the client change position slowly, sitting at the bedside first, and look for fluid deficit and antihypertensive drugs as causes.
Pain assessment: A systematic inquiry into pain location, intensity, quality, onset, duration and aggravating or relieving factors, often guided by mnemonics such as PQRST or OLDCARTS. Pain is what the client says it is: use numeric or faces scales for intensity and behavioral scales for clients who cannot self-report. Reassess and document after every intervention.
Parenteral nutrition: Giving a concentrated solution of glucose, amino acids, electrolytes, vitamins and minerals, often with lipids, into a vein when the gut cannot be used. High-osmolarity total parenteral nutrition goes through a central venous catheter, on an infusion pump and through a lumen kept for it. Give aseptic line care, monitor blood glucose, weight and laboratory values, and never stop TPN abruptly without an order.
Patient identification: Confirming a client's identity with at least two independent identifiers (e.g., full name and date of birth or medical record number) before every medication, blood product, specimen collection and procedure. A room or bed number is never an identifier. Check the wristband and, when possible, ask the client to state their name; this prevents wrong-patient errors.
Physical restraint: Any device or method that restricts a client's movement. Use it only when less restrictive measures have failed and the safety of the client or others is at stake, with a provider's order and in line with policy. Monitor circulation, skin, breathing and basic needs at regular intervals, remove it as soon as possible, and document.
Pressure injury: Localized damage to skin and underlying tissue, usually over a bony prominence or under a medical or other device, from prolonged pressure or pressure combined with friction and shear. It is staged from 1 (nonblanchable redness of intact skin) to 4 (exposed muscle, bone or tendon), plus unstageable and deep tissue injury. Prevent it with regular repositioning, pressure-redistributing surfaces, checking the skin under devices, clean dry skin and adequate nutrition.
Pulse oximetry: A noninvasive method that estimates arterial oxygen saturation (SpO₂) from light absorption at a finger, earlobe or forehead. In healthy adults it is usually 95–100%. Poor perfusion, cold extremities, nail polish, motion and carbon monoxide poisoning can make it misleading, and it can overestimate saturation in people with darker skin pigmentation. Interpret it alongside the client's clinical picture.
Range-of-motion exercises: Exercises that keep joints moving through their full capacity: active (done by the client), active-assisted, or passive (done by the nurse). In immobile clients they prevent contractures, muscle atrophy and circulatory problems. Move each joint slowly and with support, never past the point of pain, and stop if pain or resistance occurs.
SPIKES protocol: A six-step structure for breaking bad news: Setting (privacy, time, family if wished), Perception (what the client already understands), Invitation (how much they want to know), Knowledge (give information clearly, in small parts), Emotions (respond with empathy), and Strategy and summary (agree on next steps). The physician usually discloses the diagnosis; the nurse prepares the setting, stays and supports the client and family afterwards.
Subcutaneous injection: Injecting a drug into the fatty tissue between skin and muscle, usually at a 45–90° angle, for drugs meant to be absorbed slowly such as insulin and heparin. Common sites are the abdomen away from the navel, the back of the upper arm and the front of the thigh. Rotate sites to prevent lipohypertrophy. In orders, spell it out: SC and SQ are error-prone abbreviations.
Urinary catheterization: Passing a catheter through the urethra into the bladder to drain urine, either intermittently (straight) or as an indwelling (Foley) catheter, using sterile technique. To prevent infection, use it only when truly indicated, keep the drainage system closed, keep the bag below bladder level and off the floor, and remove it as soon as it is no longer needed.
Vital signs: The core physiological measurements: temperature, pulse, respiratory rate and blood pressure, often with oxygen saturation and pain added. They give early warning of change; compare each value with previous readings and with the client's own baseline, and report unexpected changes.