communication, exchange of information, verbal communication, involves the use of language, either spoken or written, nonverbal communication, tends to be more subtle, gives information through the use of facial expressions, gestures, body, language, and tone of voice, conflict, discord resulting from differences between people can occur when one person is unable to understand or accept other ideas or beliefs, observation, something that you notice about a patient a resident typically re related to a change in the person’s physical or mental condition, objective data, information that you obtained directly through measurements or by using one of your five senses, signs, objective observation, such as elevated temperature, a rash, or a low urine output, subjective data, information that cannot be objectively measured or assessed, symptoms, a person’s complaint, subjective observation, reporting, the spoken exchange of information between healthcare team members, recording, sometimes referred to as charting, communicating information about a patient or resident to other healthcare team members in a written or electronic form, medical record, a legal document that is formal accounting of the care a person receives from the healthcare facility, electronic health record, computer information system that stores and saves a persons medical information, Kardex, a card file containing condensed versions of each patient or residence medical records, interdisciplinary care plan, a specific individualized plan of care where healthcare team members meet with the patient or resident and family members, nursing care plan, a nursing team will develop a specific plan of care for each patient and resident, nursing process, a communication method that is used to develop the nursing care plan, nursing diagnosis, a statement that describes a problem at the person is having as well as the cause of the problem, gathered during the assessment step and developed by the nurse, interventions goals, developed by the nurse, actions that will will be taken to help the person, descriptions of what the interventions are meant to achieve, acute illness, condition characterized by a rapid onset and relatively short recovery time, chronic illness, a condition that is ongoing and needs continuous medication or treatment to control the condition, terminal illness, an illness or condition from which recovery is not expected, a patient will die as a result of their illness usually within a short period of time, growth, changes that occur physically, development, changes that occur, psychologically or socially, tasks, growth and development milestones associated with the stage they are currently in, neonate, a newborn infant 28 days or younger, puberty, the developmental stage when the secondary sex characteristics, such as enlarged breasts and facial hair appear, and the reproductive organs began to function, Menarche, the onset of menstruation, nocturnal emissions, the onset of puberty in adolescent males, menopause, cessation of menstruation and fertility in women in their early 50s

Chapter 5,6 Quiz

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