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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 |
Created by:
Crecia
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