The nursing process
Collecting information about a resident
Assessment
CNS
CPR
Cardiopulmonary resuscitation
Law that protects the privacy and security of a person's health information
HIPPA (Health Insurance Portability and Accountability Act
Build trust, injury prevention, clean, safe environment
Safety and Security
Describes a health problem that can be treated using nursing measures
Nursing Diagnosis
CHF
Congestive heart failure
C.diff
Clostridium difficile
A legal document that organizes all the information about care of a single resident in one document
Medical Record
Acceptance into a community, personal achievement
Self-Esteem
Setting priorities and goals for a resident
Planning
c/o
complains of
COPD
Chronic obstructive pulmonary disease
The written/electronic documentation of care and observations by the health care team
Recording
Sleep, shelter, nutrition, breathing
Physiological Needs
Nursing measures carried out during resident care
Implementation
DM
Diabetes mellitus
DAT
Diet as tolerated
The oral account of care done and observations noted
Reporting
Reaching one's maximum potential
Self-Actualization
Measuring to determine if priorities and goals were met that impacted resident care
Evaluation
CS
central supply
DOB
date of birth
Observations using the senses
Objective Data
Free from social isolation, meaningful relationships
Love and Belonging