Stack #35361
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| assessment | collecting information about the person; a step in the nursing process
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| chart | another term for the medical record
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| communication | the exchange of information--a message sent is received and interpreted by the intended person
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| conflict | a clash between opposing interests or ideas
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| evaluation | to measure if goals are met or if progress is made; a step in the nursing process
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| goal | that which is desired in or by the person as a result of nursing care
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| implementation | to perform or carry out; a step in the nursing process
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| Kardex | a type of card file that summarizes information found in the medical record; includes drugs and treatments, diagnosis, routine care measures, and special equipment used by the person
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| medical diagnosis | the identification of a disease or condition by a doctor
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| medical record | a written account of a person's illness and response to the treatment and care given by the health team; chart
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| minimum data set (MDS) | a form used by nurses in nursing centers to assess a resident's mental, physical, and psychosocial functioning
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| nursing care plan | a written guide giving direction about the nursing care a person should receive
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| nursing diagnosis | a statement describing a health problem that is treated by nursing measures; a step in the nursing process
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| nursing intervention | an action or measure taken by the nursing team to help the person reach a goal
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| nursing process | the method used by RNs to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation
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| objective data | information that is seen, heard, felt, or smelled by another person; signs
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| observation | using the senses of sight, hearing, touch, and smell to collect information about a person
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| planning | setting priorities and goals; a step in the nursing process
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| recording | writing or charting patient or resident care and observations
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| reporting | a verbal account of patient or resident care and observations
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| resident assessment protocol (RAP) | triggers and guidelines used indeveloping the comprehensive care plan
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| signs | objective data
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| subjective data | that which is reported by a person and is not observed by others using the senses; symptoms
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| symptoms | subjective data
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| triggers | clues that direct the caregiver to the appropriate resident assessment protocol (RAP)
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Created by:
jstruss
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