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Care planning 5 steps
Assessment, nursing, diagnosis, planning, implementation, evaluation
Nursing diagnosis
describes a health problem that can be treated by nursing measures; a step
in the nursing process
medical diagnosis
the identification of a disease or condition by a doctor
Planning involves...
Setting priorities and goals and developing measures or actions to help the
client meet these goals
Intervention
Action or measure taken by the nursing team to help the client reach a goal
ADL
activities of daily living
BDL
Behaviours of daily living
CCL
Continency care level ( size of depends)
Cognitive level
Memory and orientation
CCAC
Community Care Access Centre, arrange for community in home supports
as well as admission into LTC facilities
Care plan
,Document that details the care and services the client must receive each
shift
Evaluation
To measure and assess the clients progress toward meeting goals that are
outlined in the care plan
Objective data
information that is seen, heard, felt, or smelled by an observer; signs
Subjective data
things a person tells you about that you cannot observe through your
senses; symptoms
Graphic sheets
are used to record measurements and observations made daily, every shift ,
or 3-4 times a day
Kardex
A type of card file that summarizes information found in the medical
record-drugs, treatments, diagnoses, routine care measures, equipment,
and special needs
Charts
A written account of the clients condition, illness, the care and treatment
given to a client and the clients response to care
SOAP
subjective, objective, assessment, plan
PIE
Problem, intervention, evaluation
Restorative care
Maintaining the current level of functioning while preventing decline
Rehabilitation
Restore function to former levels
ABI
acquired brain injury
, Acute care
Hospital, less than 6 months
Transition
Moving a client from one area to another
Admission
The official entry of a client into any health care facility where the client
will be staying for any period of time, from overnight to indefinitely
Discharge
The official departure of a client from a hospital or other health care
facility
Lithotomy
Feet up in stirups
Preoperative period
Time period before surgery
Anaesthesia
Loss of feeling or sensation produced by a medication
3 types of anaesthesia
General, regional, local
4 vital signs
temperature, pulse, respiration, blood pressure
Body temperature
Amount of heat in the body
Tympanic temperature
Temperature taken in the ear
Axillary temperature
Underarm
Rectal temperature
Rectum , rarely used