Term
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Definition
| limited to facts or factual accounts of observations rather than opinions or interpretations of observations. |
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Term
| Appropriate Documentation |
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Definition
| information must have direct bearing on client’s health and must use standard abbreviations and symbols. |
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Term
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Definition
| step 1 of the nursing process, is the collection , organization, and validation of subjective and objective data. |
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Term
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Definition
| Charting by exception method of documentation uses a predetermined standards and norms to record only the significant findings or exceptions. Follow outside of SOC. Developed by situation |
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Term
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Definition
| A compilation of all written documentation regarding a client's progress and the care provided |
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Term
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Definition
| a number of things of the same kind, growing or held together; a bunch. In nursing we cluster together common information to form a diagnosis. |
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Term
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Definition
| all information has been included for the of care. comprehensive health assessment, health history, focused interview and physical assessment |
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Term
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Definition
| transferring the client record to electronic format |
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Term
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Definition
| Practice of keeping client information private |
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Term
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Definition
| Info that does not change over time: race, sex, blood type |
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Term
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Definition
| Purposeful thinking to resolve problems and manage situations that arise. |
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Term
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Definition
| stimulus that determines or may prompt the nature of a persons response. |
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Term
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Definition
| store or bank of information in a form that can be processed by a computer; organized collection of data |
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Term
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Definition
| Any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. |
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Term
| Disease-prevention activities |
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Definition
| Activities designed to protect patients or other members of the public from actual or potential health threats and their harmful consequences. Primary secondary and tertiary .. know |
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Term
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Definition
| In a patient record) a graphic summary of several changing factors, especially the patient's vital signs or weight and the treatments and medications given. Form of charting |
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Term
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Definition
| This type of documentation is intended to address specific purpose or focus, that is, a symptom, strength, or need. |
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Term
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Definition
| an interview that enables the nurse to clarify points, to obtain missing information, and to follow up on verbal and nonverbal sues identified in the health history |
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Term
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Definition
| optimal functioning or interactive process between internal and external environment. |
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Term
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Definition
| An evaluation of the health status of an individual by performing INSPECTION, PALPATION, PERCUSSION, AND AUSCULTATION. |
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Term
| Health-maintenance activities |
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Definition
| The behaviors that a person, in a stable health, uses to maintain or improve that state over time |
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Term
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Definition
| the process of enabling people to increase control over their health and its determinants, and thereby improve their health |
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Term
| Health-promotion activities |
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Definition
| Activities that a person would do to promote health. stop smoking, eat good, stress management etc. |
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Term
| Health-protection activities |
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Definition
| environmental or regulatory measures that seek to protect the health |
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Term
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Definition
| mind body and spirit all interact within the environment. |
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Term
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Definition
| Automated, coordinated, self-regulating physiologic process that maintains most steady-states in an organism. Balanced. |
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Term
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Definition
| Person or group who actually carrying the illness. Harbors or nourishes the illness. |
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Term
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Definition
| Product of the disharmonious interaction among mind, body, emotions, and spirit. |
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Term
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Definition
| putting the plan into work. |
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Term
| Interpretation of findings |
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Definition
| Making determinations about all of the data collected in the health assessment process... Cues found subjective objective info to break it down for people to understand. |
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Term
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Definition
| goal directed conversation in which the nurse questions the client to get pertinent information |
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Term
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Definition
| A statement of a health problem or of a potential problem in the clients health status that a nurse is licensed and competent to treat. Analyzes and synthesis the data... what needs to be fixed. |
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Term
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Definition
| a narrative record that includes words, sentences, phrases, or lists to indicate judgments made about data plans to address concerns, and actions taken to meet health needs of clients. |
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Term
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Definition
| Systematic approach to providing nursing care using assessment, diagnosis, outcome identification, planning, implementation, and evaluation...ADOPIE |
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Term
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Definition
| observable, measurable information that can be validated or verified |
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Term
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Definition
| the part of the health assessment representing a synthesis of the information obtained in a physical examination |
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Term
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Definition
| Development of nursing strategies designed to make client problems better |
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Term
| Primary Health Indicators |
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Definition
| Health promotion, education, protection, and screening... physical activities, overwight, tobacco, drugs, sex behavior, shots, |
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Term
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Definition
| prevent anything that changes high level of wellness... promotes wellbeing and health. |
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Term
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Definition
| pertains to the client. The client is the only one who can describe personal symptoms, factors leading to the current health concern. |
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Term
| Problem-Oriented Charting |
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Definition
| Your initial SOAP method will provide (S) subjective impressions, (O) initial assessment information and/or baseline information (A) analysis of your initial information that leads to your (P) plan for treatment. APIE... assessment problem intervention evaluation |
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Term
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Definition
| means to determine measureables. height weight inches centimeters |
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Term
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Definition
| emphasis is on resolving health problems and preventing serious consequences. Screenings, blood tests, x-rays, surgery, and dental care are strategies utilized at this level of prevention. |
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Term
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Definition
| is a person or record that provides additional information about the client. |
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Term
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Definition
| things you can measure; an objective evidence of disease especially as observed and interpreted by the physician rather than by the patient or lay observer |
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Term
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Definition
| Observations that involve personal feelings, attitudes, and perceptions. Subjective data can be measured quantitatively or qualitatively. |
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Term
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Definition
| subjective evidence of disease or physical disturbance observed by the patient |
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Term
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Definition
| Activity aimed at restoring the individual to the highest possible level of health and function. |
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Term
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Definition
| Data that can be measured on a scale and compared with other data. Also known as continuous data, it can be added to or subtracted from other variable data. |
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Term
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Definition
| A state of life that is balanced, personally satisfying, and characterized by the ability to adapt and to participate in activities that enhance the quality of life, physically spiritually, mentally. |
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Term
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Definition
| pain that lasts only through the expected recovery period from illness, injury, or surgery, whether it has a sudden or slow onset and regardless of the intensity |
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Term
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Definition
| to attack or infect as a disease, disterbance to homeostasis.. |
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Term
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Definition
| using a stethoscope to listen to the sounds produced by the body |
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Term
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Definition
of or relating to or being biography
written history of ones life. |
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Term
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Definition
| total amount of blood circulating within the entire vascular system |
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Term
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Definition
| placement of the palm of non-dominant hand flat against the body surface and striking the non-dominant hand with the dominant hand |
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Term
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Definition
| a resting heart rate under 60 bpm |
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Term
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Definition
| pain that is prolonged, usually recurring or persisting over 6 months or longer, and interferes with functioning |
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Term
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Definition
| pain that originates in the skin or subcutaneous tissue |
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Term
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Definition
| pain that is diffuse and arises from ligaments, tendons, bones, blood vessels, and nerves, which tends to last longer than cutaneous pain |
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Term
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Definition
| part of the stethescope that screens out low pitched sounds i.e lung and heart sounds. separates thoracic from abdominal cavities, |
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Term
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Definition
| lowest arterial pressure, between ventricular contractions when heart is at rest |
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Term
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Definition
| tapping on the middle finger of your nondominant hand over the body part |
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Term
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Definition
| a quality of sound elicited by percussion, being short and high-pitched with little resonance... heard over soldi body organs such as the liver... over solid organs |
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Term
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Definition
| a peculiar sound lacking resonance, heard on percussing an abnormally solid part. Dull precussion tone that is soft and has short duration … oer solid tissue |
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Term
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Definition
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Term
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Definition
| abnormally increased pain sense |
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Term
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Definition
| exaggerated resonance on percussion... abnormally loud asciltiary with low with long duration |
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Term
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Definition
| Abnormally high body temperature, usually resulting from infection, medication, or head injury, and sometimes brought about intentionally to treat diseases, especially certain cancers. |
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Term
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Definition
| Hypothermia, a potentially fatal condition, occurs when body temperature falls below 95°F (35°C). |
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Term
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Definition
| using fingers of the dominant hand to tap or using an object to tap |
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Term
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Definition
| systematic visual examination of the client |
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Term
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Definition
| A pain that is highly resistant to relief; example: advanced malignancy |
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Term
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Definition
| Emotional state or outlook. |
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Term
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Definition
| Pain resulting from current or past damage to peripheral or central nervous system. |
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Term
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Definition
| Receptors that transmit pain. |
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Term
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Definition
| a period or process of introduction and adjustment |
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Term
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Definition
| Fall in blood pressure associated with a change in position.. changes when lying down and sits up. |
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Term
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Definition
| The level of oxygenation in the blood |
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Term
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Definition
| An unpleasant sensation caused by noxious stimulation of the sensory nerve endings. It is an subjective feeling an individual response to the cause. |
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Term
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Definition
| assessment of the intensity of pain using a standardized measurement tool. The tools, which may be numbers, words, or pictures, provide the client the opportunity to describe the degree of discomfort. |
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Term
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Definition
| lowest intensity at which a certain person perceives a stimulus to be painful. pain begins to be felt |
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Term
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Definition
| the maximum amount and duration of pain that an indiviual is able to endure without relief |
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Term
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Definition
| a phase of the examination procedure in which the sense of touch is used to gather information essential for diagnosis |
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Term
| Peripheral vascular resistance |
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Definition
| Resistance to the flow of blood determined by the tone of the vascular musculature and the diameter of the blood vessels; responsible for blood pressure when coupled with stroke volume |
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Term
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Definition
| painful sensation experienced in missing a body part (amputation) or paralyzed area. |
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Term
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Definition
| pain that is felt in surrounding tissues.. percieved in one location and moves to other near by |
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Term
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Definition
| extent to which a person can move joints and muscles |
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Term
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Definition
| A pain felt in a part of the body that is considerably removed or distant from the area actually causing the pain |
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Term
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Definition
| A long, low pitched hollow sound elicited with percussion over the lungs. |
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Term
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Definition
| A instrument used to measure arterial blood pressure. |
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Term
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Definition
| Protection against blood and body fluid xmssn of potentially infectious agents. |
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Term
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Definition
| a medical instrument for listening to the sounds generated inside the body, such as heart sounds, respirations, and bowl sounds. There are three pieces to a stethoscope, binaurals (earpieces), the flexible tubing and the diaphragm. |
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Term
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Definition
| The highest arterial blood pressure during the height of a ventricular contraction; while the heart is beating. 1st pressure measurement |
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Term
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Definition
| abnormally rapid heartbeat (over 100 beats per minute) |
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Term
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Definition
| A loud high pitched drum like tone of medium duration characteristic of an organ that is filled with air. Usually from stomach or abdomen. |
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Term
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Definition
| elasticity of smooth muscle in the arterial walls. |
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Term
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Definition
| Pain that result from stimulation of pain receptors deep within the body, such as the abdominal cavity, cranium, or the thorax. |
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Term
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Definition
| Viscosity is a measure of a fluid's resistance to flow... Thickness |
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Term
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Definition
| giving full time attention to verbal and non-verbal messages |
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Term
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Definition
| clients response to “yes” “no” or one-word answers |
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Term
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Definition
| of information, feelings, thoughts, and ideas |
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Term
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Definition
| speaking to the client in specific terms rather than in vague generalities |
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Term
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Definition
| intellectual and emotional awareness and understanding of another's thoughts, feelings, and behavio... ability to put yourself in other persons shoes. |
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Term
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Definition
| : A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problem(s). |
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Term
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Definition
| Actually possessing the alleged or apparent attribute or character … honest. |
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Term
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Definition
| Paying undivided attention to what the client says and does. |
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Term
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Definition
| questions that cant be answered as yes or no and cause the respondant to express how they think and feel |
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Term
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Definition
| A restatement of a text or passage giving the meaning another form; rewording |
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Term
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Definition
| encompasses the mental, emotional, social, and spiritual dimensions of health; mental, environmental, and social health |
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Term
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Definition
| The person or persons to whom a message is sent. |
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Term
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Definition
| is repeating the client’s verbal and nonverbal message for the client’s benefit. A way of showing client that nurse empathasize’s or is in tune with client’s thoughts, feelings, and experiences. |
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Term
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Definition
| an organized approach to human spirituality which usually encompasses a set of narratives, symbols, beliefs and practices, often with a supernatural or transcendent quality, that give meaning to the practitioner's experiences of life through reference to a higher power, God or gods, or ultimate truth |
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Term
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Definition
| The feelings and beliefs one holds about themselves. |
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Term
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Definition
| Someone who transmits information to a receiver. |
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Term
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Definition
| Sacred or holy matters that belong to or relate to a god or church. |
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Term
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Definition
| Tying together the various messages that the client has communicated through the interview. |
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