| A | B |
|---|
| communication | exchange of information |
| verbal communication | spoken or written language |
| nonverbal communication | facial expressions, gestures, body language and tone of voice |
| conflict | discord resulting from differences between people |
| observations | something you notice about a patient or resident |
| objective data | vital signs, skin color, urine color or odor |
| subjective data | information that cannot be measured or assessed |
| symptom | for example a resident tells you they have a headache |
| reporting | spoken exchange of info between health care team members |
| medical record (chart) | legal document about a person's current condition, diagnosis and treatment |
| medical administration record (MAR) | record of medications given and by whom |
| Electronic health record (EHR) | computer information system that stores and saves a person's medical information |
| Kardex | condensed version of the medical record |
| nursing care plan | specific plan of care for each patient or resident |
| nursing process | the method used to develop the nursing care plan |
| acute illness | rapid onset and short recovery time |
| chronic illness | ongoing condition |
| terminal illness | illness or condition from which recovery is not expected |
| surgical patients | patients with illnesses treated by surgery |
| medical patients | patients with illnesses treated with things other than surgery such as medication, radiation or PT |
| obstetrical patients | those who are pregnant or have just given birth |
| pediatric patients | children and adolescents |
| rehabilitation patients | those undergoing therapy to restore their highest level of physical, emotional, mental or vocational function |
| growth | physical changes |
| development | psychological or social changes |
| neonate | newborn 28 days or younger |
| toddler | ages 1 - 3 years |
| preschool | ages 3 - 5 years |
| School-age | ages 5 - 12 years |
| adolescence | ages 12 - 20 years |
| puberty | appearance of secondary sex characteristics |
| menarche | onset of menstruation |
| young adult | ages 20 - 40 years |
| middle adulthood | ages 40 - 65 years |
| later adulthood | ages 65 - 75 years |
| older adulthood | ages 75 and beyond |
| physiological needs | oxygen, food, shelter |
| safety and security needs | hand hygiene; walker is left close to the resident, call light is within reach |
| love and belonging needs | taking an interest in a person and showing them respect |
| self-esteem needs | providing privacy |
| self-actualization | reaching fullest potential |
| intimacy | felling of emotional closeness |
| race | skin color, body stature, facial features , and hair texture |
| religion | spiritual beliefs |
