Anterior / Ventral
At or toward the front of the body. Also called ventral.
Medical record
The legal account of a persons condition and response to treatment of care. Also called chart and clinical record
Communcation
The exchange of information. A message sent us received and correctly interpreted by the intended person.
Distal
The part farthest from the center of the post of attachment.
Dorsal / posterior
At or toward the back of the body or body part.
Kardex
A type of card file that summarizes information found in the medical record. Drugs. Treatment. Diagnoses. Routine care measures. Equipment. Special needs. It is not a permanent medical record.
Report care and observations to the nurse
When there is a change from normal or a change in the persons condition. Report these changes at once. When the nurse asks you to do so. When you leave the unit. Before the end of shift report.
end of shift report
a report that the nurse gives at the end of the shift to the on-coming shift. They report the care given. The Care given during other shifts. The persons current condition. Likely changes in the persons condition.
Recording
When recording report what you observed. What you did. The persons response.
Where does the nurse describe the nursing care given?
The progress notes.
You need to know if the resident uses a hearing aid what do you check?
The kardex
Assessment
Collecting information about the person. A step in the nursing process.
Evaluation
To measure 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 interventions. Nursing measures or nursing actions. In the care plan. A step in the nursing process.
Medical diagnosis
The identification
Lateral
Away from the midline. At the side of the body or body part.
Medial
At or near the midline
Progress note
Describes the care given and the persons response and progress. The nurse records signs and symptoms. Information about treatments and drugs. Information about teaching and counseling. Procedures performed by the doctor. Visits by other health team member
Graphic sheet
Used to record measurements and observations made daily. Info includes vital signs. Weight. Blood pressure. Temperature. Pulse. Respirations. Bowel movements. Doctors visits.
Flow sheets
Used to record frequent measurements or observations. If vital signs are measured every 30 minutes.
Proximal
Part nearest to the center or point of attachment
How to communicate
Use words that mean the same thing to the person. Use familiar words. Be brief and concise. Give information in a logical and orderly way. Give facts and be specific.
What is the medical record?
A permanent and legal document. Contains admission record. Health history. Physical examination results. Doctors orders. Progress notes. Graphic sheets. Lab results. X-rays. Therapy records. Consultation reports. Assessments. Special consents.
Sign
Objective data. Something you see, hear, feel, or smell on the person. You can feel a pulse. You can see Urine color. You can see someone vomit.
Symptom
Subjective data. Something the person tells you about that you cannot see. Headache. Nausea. Pain.
Anterior / Ventral
At or toward the front of the body. Also called ventral.
Medical record
The legal account of a persons condition and response to treatment of care. Also called chart and clinical record
Communcation
The exchange of information. A message sent us received and correctly interpreted by the intended person.
Distal
The part farthest from the center of the post of attachment.
Dorsal / posterior
At or toward the back of the body or body part.
Kardex
A type of card file that summarizes information found in the medical record. Drugs. Treatment. Diagnoses. Routine care measures. Equipment. Special needs. It is not a permanent medical record.
Report care and observations to the nurse
When there is a change from normal or a change in the persons condition. Report these changes at once. When the nurse asks you to do so. When you leave the unit. Before the end of shift report.
end of shift report
a report that the nurse gives at the end of the shift to the on-coming shift. They report the care given. The Care given during other shifts. The persons current condition. Likely changes in the persons condition.
Recording
When recording report what you observed. What you did. The persons response.
Where does the nurse describe the nursing care given?
The progress notes.
You need to know if the resident uses a hearing aid what do you check?
The kardex
Assessment
Collecting information about the person. A step in the nursing process.
Evaluation
To measure 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 interventions. Nursing measures or nursing actions. In the care plan. A step in the nursing process.
Medical diagnosis
The identification
Lateral
Away from the midline. At the side of the body or body part.
Medial
At or near the midline
Progress note
Describes the care given and the persons response and progress. The nurse records signs and symptoms. Information about treatments and drugs. Information about teaching and counseling. Procedures performed by the doctor. Visits by other health team member
Graphic sheet
Used to record measurements and observations made daily. Info includes vital signs. Weight. Blood pressure. Temperature. Pulse. Respirations. Bowel movements. Doctors visits.
Flow sheets
Used to record frequent measurements or observations. If vital signs are measured every 30 minutes.
Proximal
Part nearest to the center or point of attachment
How to communicate
Use words that mean the same thing to the person. Use familiar words. Be brief and concise. Give information in a logical and orderly way. Give facts and be specific.
What is the medical record?
A permanent and legal document. Contains admission record. Health history. Physical examination results. Doctors orders. Progress notes. Graphic sheets. Lab results. X-rays. Therapy records. Consultation reports. Assessments. Special consents.
Sign
Objective data. Something you see, hear, feel, or smell on the person. You can feel a pulse. You can see Urine color. You can see someone vomit.
Symptom
Subjective data. Something the person tells you about that you cannot see. Headache. Nausea. Pain.