Chapter 5 Flashcards
assessment
Collecting information about the person; a step in the nursing process
comprehensive care plan
A written guide about the care a person should receive; developed by the interdisciplinary team (IDT); care plan
evaluation
To determine if goals in the planning step were met; a step in the nursing process
goal
That which is desired for or by a person as a result of nursing care
implementation
To perform or carry out nursing measures in the care plan; a step in the nursing process
interdisciplinary team (IDT)
Members of the departments found in a nursing center: activities, dietary, nursing, social services, rehabilitation, etc.
medical diagnosis
The identification of a disease or condition by a doctor
nursing diagnosis
Describes a health problem that can be 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 nurses use 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 an observer; signs
observation
Using the senses of sight, hearing, touch, and smell to collect information
planning
Setting priorities and goals; a step in the nursing process
signs
“objective data”
skilled care
Daily services provided by an RN and/or therapist for rehabilitation or other complex services; provided in nursing centers for short periods of time
subjective data
Things a person tells you about that you cannot observe through your senses; symptoms symptoms See “subjective data”
symptoms
“subjective data”
triggers
Information that is collected from the MDS for the care area assessments (CAAs)
ADL
Activities of daily living
CAA
Care area assessment
IDT
Interdisciplinary team
MDS
Minimum Data Set
OBRA
Omnibus Budget Reconciliation Act of 1987
POC
Point of care
RN
Registered nurse
