NA CH.4 KEY TERMS | DEFINITIONS |
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) |