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
Implentation
To perform or carry out nursing measure 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 measure; 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
see “ 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
