Chapter 5 Assisting With The Nursing Process Flashcards
Assessment
Collecting information about the person; a step in the nursing process
Comprehensive care plan
A written guide about the individual 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 founds 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
Describe a health problem that can be treated by nursing measures; 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; it’s five steps are assessment, nursing diagnosis, planning, implementation and evaluation
Objective data
Information that is seen heard felt or smell by an observer; signs
Observation
Using the senses of sight , hearing , touch, and smell to collect information
Planning
Setting priorities and goals; step in the nursing process
Residents assessment instruments RAI
Helps staff to gather information on a resident strength and needs which must be addressed in an individualized care plan
Resident Assessment Protocol (RAP)
Identify social, medical, and psychological problems and form the basis’ individualized care planning
Signs
See Objective data
Skilled care
Daily services provided by an RN and the for rehabilitation or other complex’s services provided nursing centers for short period of time
Subjective Data
Things a person tells you about that cannot observe through your senses ; symptoms
Symptoms
See subjective data
Triggers
Information that is collected from the MDS for the care area assessments (CAAs)
Utilization
Putting planned care into action in an efficient manner
CAA
Care Area Assessment
CMS
Centers for Medicare and Medicaid Services
IDT
Interdisciplinary Team
