| A | B |
|---|
| Nursing Process | Step by step process used to identify patient problems |
| Assessment | Collecting, organizing, documenting & validating patient data |
| Evaluation | Assessing the patient's response to the nursing interventions |
| Planning | Setting goals or priorities to eliminate or diminish patient problems |
| Nursing Diagnosis | Indicates the patient's actual or potential risk of a problem developing with related or causative factors |
| Implementation | Nursing interventions are performed & responses documented |
| Priority setting | Placing nursing diagnosis or nursing interventions in order of importance |
| Subjective Data | Information obtained from the patient verbally |
| Objective Data | Information obtained by the nurse through the senses and physical examination |
| Database | All the information gathered about a patient |
| Assessment | Gathering information about patients and their needs |
| MAR | Medication Administration Record |
| Etiology | Causes of the problem |
| Signs | Abnormalities that can be verified by repeat examination and are objective data |
| Symptoms | What the patient says is occurring that cannot be verified by examination and is subjective data |
| Physiologic needs | Basic needs |
| Short-term goal | Achievable within 7-10 days or before discharge |
| Long-term goal | Achievable over a period of weeks or months |
| Independent Nursing Action | Does not require a physician's order, but requires critical thinking |
| Dependent Nursing Action | Requires a physician's order to perform |
| Critical Pathway | Interdisciplinary step-by-step approach to total care of the patient |
| Quality Improvement | Program used to evaluate nursing care delivered to patients |
| Verbal communication | Written or spoken words |
| Nonverbal communication | Communication consisting of gestures, body posture, facial expression, etc |
| Active Listening | Listening for feelings as well as words |
| Therapeutic communication | Communication that promotes understanding between the sender and the receiver |
| Open-ended Questions | Broad statement requiring an answer of more than a word or two |
| Restating | Listening for basic message & rephrasing the message |
| Rapport | Establishing a feeling of trust and mutual respect |
| Empathy | Ability to understand by seeing the situation from another's perspective |
| Aphasia | Difficulty expressing or understanding written or spoken language |
| Medical Record | Legal document with documentation to record & document that care of patients has been carried out utilizing accepted standards of care |
| Charting | Documentation of patient care |
| POMR Charting | Focuses on problems or the patient |
| Source-oriented charting | Focuses on patient's disease |
| Charting by exception | Focuses on deviations from normal |
| Kardex | Quick reference for current information about the patient & ordered treatments |
