Nursing diagnosis - ANSWER-describes a health problem that can be treated by
nursing measures; a step in the nursing process
medical diagnosis - ANSWER-the identification of a disease or condition by a doctor
Planning involves... - ANSWER-Setting priorities and goals and developing measures or
actions to help the client meet these goals
Intervention - ANSWER-Action or measure taken by the nursing team to help the client
reach a goal
ADL - ANSWER-activities of daily living
BDL - ANSWER-Behaviours of daily living
CCL - ANSWER-Continency care level ( size of depends)
Cognitive level - ANSWER-Memory and orientation
Objective data - ANSWER-information that is seen, heard, felt, or smelled by an
observer; signs
Subjective data - ANSWER-things a person tells you about that you cannot observe
through your senses; symptoms
Graphic sheets - ANSWER-are used to record measurements and observations made
daily, every shift , or 3-4 times a day
Kardex - ANSWER-A type of card file that summarizes information found in the medical
record-drugs, treatments, diagnoses, routine care measures, equipment, and special
needs
Charts - ANSWER-A written account of the clients condition, illness, the care and
treatment given to a client and the clients response to care
SOAP - ANSWER-subjective, objective, assessment, plan
PIE - ANSWER-Problem, intervention, evaluation
Restorative care - ANSWER-Maintaining the current level of functioning while
preventing decline