Chapter 7 key terms Documentation and Cord Nursing Skills

Apnea

temporary cessation of breathing, especially during sleep

Assessment

evaluation of a patient or condition

Auscultation

using a stethoscope to hear sounds produced by internal organs

Base line

initial measurement or observation used for later comparison

Blood pressure (BP)

measurement of the pressure of blood in the arteries

Body mass index (BMI)

measurement that estimates the percentage of fat tissue in the body

Bradycardia

slower than normal pulse rate

Bradypnea

slower than normal respiratory rate

Call system

system that enables residents to signal that they need assistance from staff

Diastolic pressure

number that reflects the pressure when the heart is at rest between beats

Documentation

written and/or digital reports maintained by the facility relating to the resident’s care and condition

Dyspnea

difficult or labored breathing

Electronic medical record (EMR)

digital version of the patient chart and medical record

Face sheet

one-page summary of important information about a patient/resident

Fever

elevated body temperature

Flow sheet

document used to record health and activity information about a resident over a period of time

History

information from a resident’s previous health status, lifestyle, and medical treatment

History and physical (H%P)

patient/resident history combined with a physical exam

Hypertension

high blood pressure

Hypotension

low blood pressure

Inspection

careful observation of the resident’s body to determine health status

Kiosk

centrally located electronic device used to put input patient/resident date

Objective information

factual information gathered by observation

Palpation

physical examination conducted by touching the resident’s body with the fingers/and or hands

Percussion

tapping on a body area to hear the sound produced; used to determines the status of internal organs and tissues

Personal health record (PHR)

An individual health history kept by the patient, usually in electronic form

Physical examination

An organized examination of the body to determine health status; includes visual inspection, auscultation, palpation, percussion, and smell.

Policies and procedures (P%Ps)

guidelines and procedures established by a facility for daily operations and emergency/disaster situations

Protocol

An official or standard way of doing something, usually put in writing

Pulse

measure of heart rate taken by feeling the expansion of an artery as blood is pushed through where the heart contracts

Radial pulse

pulse measurement taken by feeling the radial artery at the wrist.