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NA CH. 4 KEY TERMS

Stack #35361

NA CH.4 KEY TERMSDEFINITIONS
assessment collecting information about the person; a step in the nursing process
chart another term for the medical record
communication the exchange of information--a message sent is received and interpreted by the intended person
conflict a clash between opposing interests or ideas
evaluation to measure if goals are met or if progress is made; a step in the nursing process
goal that which is desired in or by the person as a result of nursing care
implementation to perform or carry out; a step in the nursing process
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
medical diagnosis the identification of a disease or condition by a doctor
medical record a written account of a person's illness and response to the treatment and care given by the health team; chart
minimum data set (MDS) a form used by nurses in nursing centers to assess a resident's mental, physical, and psychosocial functioning
nursing care plan a written guide giving direction about the nursing care a person should receive
nursing diagnosis a statement describing a health problem that is treated by nursing measures; a step in the nursing process
nursing intervention an action or measure taken by the nursing team to help the person reach a goal
nursing process the method used by RNs to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation
objective data information that is seen, heard, felt, or smelled by another person; signs
observation using the senses of sight, hearing, touch, and smell to collect information about a person
planning setting priorities and goals; a step in the nursing process
recording writing or charting patient or resident care and observations
reporting a verbal account of patient or resident care and observations
resident assessment protocol (RAP) triggers and guidelines used indeveloping the comprehensive care plan
signs objective data
subjective data that which is reported by a person and is not observed by others using the senses; symptoms
symptoms subjective data
triggers clues that direct the caregiver to the appropriate resident assessment protocol (RAP)
Created by: jstruss
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