Clinical chapter 5 Flashcards
(48 cards)
define communication
the exchange of information
define Verbal communication
way of communicating that uses written or spoken language
define non verbal communication
way of communicating that uses facial expressions, gestures, body language instead of verbal comm
define conflict
discord resulting from differences b/w people; can occur when one person is unable to understand or accept another’s ideas or beliefs
define observation
something that you notice about the pt typically relate to a change in the person’s physical condition
define objective data
info that is obtained directly through measurements or by using one of the five senses
define signs
objective observation compare with symptoms
define subjective data
info that cannot be objectively measured or assessed
define symptoms
subjective observations compare with signs
define reporting
the spoken exchange of info bw hc team members
define recording
communicating info about a pt to other hc team members in writtten form (charting)
define medical record
legal coc with info about pts current condition, the measures taken by staff to dx and treat condition and pts response to treatment and care
define EHR
Electronic health record computer sys that stores and saves person’s med info
define Kardex
card or electric file cntains condensed versions of each pts medical record
define interdisciplinary care plan
specific care plan of care for each pt dev with input from all members of the team
define Nursing Care Plan
specific plan for each pt developed by the nursing team
define nursing process
process that allows members of nuring team to communicate with each other regarding the pts specific needs, what steps will be taken , whether steps were effective, 5 parts 1. assessment, 2. diagnosis, 3. planning, 4. implementation, 5. evaluation
define nursing diagnosis
statement that describes a problem the person is having that can be identified and treated by the nursing staff indep.
define interventions
actions taken by nursing team to help pt
define goals
descriptions of what nursing interventions (actions) are meant to achieve
What is communication
back and forth of info, exchange, with giving and receiving
who are receiver and sender
sender and receiver are the 2 people. Sender has info to share in th form of a message and receiver is who message is intended for
what Is feedback
return message that allows sender know the message was received and understood
what are 2 major forms of communications
verbal and non verbal, verbal incl sign language, is deliberate, expresses thought , gives specific info to another pers. NON verbal is subtle, use of facial express, gestures, body langua tone
