Module 4
Legal document that outlines laws or rules
What is an act
Information reported by a client that cannot be directly observed by others
Subjective data
is a card file that summarizes information in the chart. It usually includes the client’s current diagnosis, medications, treatments, any special equipment needs, and routine care measures
What is a Kardex
A writing system for visually impaired persons that uses raised dots for each letter of the alphabet
What is braille
Difficulty speaking and understanding language. Also known as global aphasia
expressive–receptive aphasia
A collection of data that is gathered during the process of providing nursing care
What are minimum data sets
A document that details the care and services the client must receive
What is a care plan
A legal document that details a client’s condition or illness and responses to care
What is a chart
An eye disease that causes pressure within the eye and vision impairment
What is glaucoma
Electronic devices that use a combination of screen reading, magnification systems, and alternate input provide computing access to clients with such impairments
What are communication boards or aids
FDAR
What is focus, data, action and response charting
Information about a client’s health gained through observation and the use of other senses.
What is objective data
record actions relating to hygiene, food and fluids, elimination, rest and sleep, mobility, activity, and social interactions
What is ADLs checklist
Inability to correctly move the muscles used to speak, even though the muscles themselves are intact
What is apraxia of speech
A collection of facts from which conclusions may be drawn
What is Data
A statement describing a health problem that is treated by nursing measures
What is nursing diagnosis
record measurements and observations made on every shift, or three to four times per day. Information may include the client’s blood pressure, temperature, pulse, respirations, height, and weight.
What is graphic sheet
Difficulty speaking clearly, because of weakness or paralysis in the muscles used for speech
What is dysarthria
Arranged in order of time of occurrence.
What is Chronological
The method used by nurses and case managers to plan the client’s care with the health care team
What is care-planning process/ nursing process
The breakdown (degeneration) of the macula (the light-sensitive part of the retina).
Age-related AMD
Difficulty speaking or writing.
What is expressive aphasia