| A | B |
|---|
| Medical Record | written or electronic account of a person's condition, response to treatment, and care |
| Assessment | Collecting information about the person |
| Goal | Desired by the person as a result of nursing care |
| Objective data | Information that is seen,heard,felt,or smelled |
| Symptoms | Subjective data |
| Admission | Official entry of person into agency |
| Anesthesia | The loss of feeling or sensation |
| Pre-operative | Before surgery |
| Constrict | To narrow |
| Advance directive | Document stating a person's wishes about health care |
| Terminal illness | Illness or injury no recovery |
| Communication | The exchange or information |
| Evaluation | to measure if goals in planning step were met |
| Implementation/intervention | to perform or carry out nursing measures in the care plan |
| Observation | using sight,hearing,touch,and smell to collect information |
| Recording | written account of care and observations charting |
| Discharge | Offical departure of person from agency |
| Embolus | Blood clot that travels through the vascular system |
| Post-operative | After surgery |
| Cyanosis | Bluish color |
| Postmortem | Care of body after death |
| Chyne-stokes respiration | respirations increase in rate and depth and become shallow and slow |
| Care plan | written guide about person's care |
| Nursing diagnosis | health problem that can be treated by nursing measure |
| Nursing process | method nurses us to plan and deliver nursing care |
| Subjective Data | Things person tells you that you can't see |
| Reporting | The oral account or care and observations |
| Transfer | Moving person from one room or nursing unit to another |
| Thrombus | A blood clot |
| Compress | Soft pad applied over body area |
| Hyperthermia | Body temperature that is high |
| Rigor Mortis | Stiffness or rigidity skeletal muslces |
| Reincarnation | Belief that spirit or soul is reborn |
| Autopsy | Examination of body after death |
| Hypothermia | Body temperature that is low |
| General anesthesia | Loss of consciousness and all feeling or sensation |
| Local anesthesia | Loss of feeling or sensation in small area |
