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Fundamentals 2 Vocab
Term | Definition |
---|---|
Objective data | Signs; Observable and measurable facts |
Subjective data | Symptoms; information that only the client feels and can describe |
Database assessment | Initial information about the clients physical, emotional, social and spiritual health That is obtained during the admission interview and physical examination;it is lengthy and comprehensive. |
Focus assessment | Information that provides more details about specific problems and expands the original database. Period |
Functional assessment | A comprehensive evaluation of a clients physical strength and weaknesses. |
Minimum Data Set (MDS) | A standardize tool for improving care based on ongoing assessments; all Medicare and Medicaid funded nursing homes and home care agencies must periodically complete these |
Collaborative problems | Potential complications from a disorder, test, or treatment that the nurse cannot treat independently (Ex. - hemorrhage) *Monitoring for Complications |
Outcome criteria | Goals |
Maslow’s Hierarchy of Human Needs | PS LES Physiologic ~ Safety and Security ~ Love and Belonging ~ Esteem and Self-Esteem ~ Self Actualization |
Short-term goals | Outcomes achievable in a few days to one week |
Long-term goals | Outcomes that take weeks or months to accomplish |
The Joint Commission | A not-for-profit organization that accredits healthcare organizations in the United States |
Standards for care | They are agency specific policies that indicate which activities will be provided to ensure quality client care |
Nursing orders | Directions for a clients care; within a nursing care plan it identifies the what, when, where and how for performing nursing interventions |
Nursing care plans | Written assignments on a standardized worksheet that contains a column for nursing diagnosis, outcome criteria, nursing interventions and the rationale for each assigned client |
Concept mapping | Also known as care mapping; it is the same thing as a care plan but in graphic or picture form |
NAND-I or NANDA International | The authoritative organization for developing and approving a nursing diagnosis |
Ancedotal |