A Compiled List of Words Anywhere?

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Is there a complied list of words that are the standard ones used for data collection and assessments to use for our careplans for beginning nursing students?

We read and study our book for basic data collection and head to toe assessement and learn what the book tells us and then for our lab class we are told:

we are not allowed to use normal- we don't know what normal is yet.

we cannot use agitated because that could have different meaning for different patients

we cannot use good skin tugor because we don't know what good is.

we can only use PEERL and no A since we don't know how to measure A yet.

we cannot use edema as we only know swelling.

So I am wondering if there is a list of good descriptive words that are the standards and commonly used for assessment and data collection?

Thanks~~

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Specializes in Med/Surg, Tele, IM, OB/GYN, neuro, GI.

we've never done a beginning nurses student assessment. we do the same one that they do at the hospital but i'll try to help.

is there a complied list of words that are the standard ones used for data collection and assessments to use for our careplans for beginning nursing students?

we read and study our book for basic data collection and head to toe assessement and learn what the book tells us and then for our lab class we are told:

we are not allowed to use normal- we don't know what normal is yet.

we can't use normal either because normal has a different meaning to everybody. i say what i'm looking at ex. for peripheral pulses i will put that they were all felt and only note if they were abnormal/absent. same with bowel sounds i put heard in all four quadrants and only no if they're abnormal/absent.

we cannot use agitated because that could have different meaning for different patients

same thing with us agitated means different things to different people. i'll put pt was uncooperative if i was trying to do something and s/he wouldn't let me.

we cannot use good skin tugor because we don't know what good is.

we don't use "good" we use elastic (if it goes back to where you pinched), loose (if it stays in the position that you pinched), or tight (if it is too hard to pinch).

we can only use peerl and no a since we don't know how to measure a yet.

we can use perrla so i don't have any advice on this.

we cannot use edema as we only know swelling.

edema is from retaining water so say that.

so i am wondering if there is a list of good descriptive words that are the standards and commonly used for assessment and data collection?

thanks~~

hope this helps some.

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Thank you ~ that's a great start!

We were given assessment sheets and told to use our P&P, so we viewed each system, read each section, and then we were all slammed!

They also told us to watch vidoes, we our clinical group did and the vidoes went pretty much hand in hand with the book but again we were all incorrect.

Do you receieve a skills kit for lab, our program does not have one to purchase, so we only get a one time deal to do our skills, but we watch the vidoes and some are listed in the P&P study guide, however there are slight variations or the equipment is not always the same.

I feel as if I have been tossed in the ocean and it's either sink or swim!

Even when our teachers run out of lecture time they tell us we are responsible for any and all on the test~ anything is fair game!

I made an A for my last course but our program has already lost 25 or so just from the first class alone~

Thanks again for your reply~ it will be a be a big help!!

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How about these:

BEHAVIORAL ASSESSMENT:

Cooperative, uncooperative, angry, calm, upset, depressed, combative, anxious

affect is:full, blunted, flat, labile

mood to affect is congruent or incongruent

MENTAL STATUS ASSESSMENT:

awake/alert, oriented X's 1,2, or 3, disoriented X's 1,2, or 3, anxious, unresponsive, responds to verbal, responds to stimuli, non-verbal, aphasic, combative

EXTREMITY MOVEMENT:

weakness, flexion, extension, flaccid, contracted

CARDIOVASCULAR ASSESSMENT

heart rate: within normal range, irregular, tachycardia, bradycardia

peripheral pulses: strong, weak, diminished, absent, bounding

edema: swelling, puffy

RESPRIRATORY ASSESSMENT

airway: patent, obstructed

Breathing: spontaneoius, assisted, apnea, labored, shallow, deep, snoring, gasping

Breath sounds: CTA (clear to assulcation), diminished, absent, coorifice/rhonchi, crackles/rales, wheezing

GI ASSESSMENT

Abdomen: soft, firm, distended

Bowel sounds: + X 4 quads, or what ever many quads, hypoactive, hyperactive

GU ASSESSMENT

urine clarity:describe..clear, cloudy, mucous

color: describe..yellow, amber, straw

INTEGUMENTARY ASSESSMENT

color: normal for client, pale, cynotic, flushed, jaundiced, mottled

skin character, warm, cool, moist, dry

skin turgor: skin lifts easily and snaps back, sluggish/poor

mucus membranes:moist & intact, pink, red, dry, cracked, blistered

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Specializes in med/surg, telemetry, IV therapy, mgmt.

you have to collect and compile your own list of what words to use to describe your assessment information. you are going to find these listings in a lot of places. most hospital daily nursing flow sheets now have a kind of check off assessment on them for the nurses. grab a blank one from every facility you go to and save it in a file at home. if you have a copy of taber's cyclopedic medical dictionary you will find a 7-page nursing assessment form in the middle of it under "nursing". you will find a number of good descriptors in it to use in doing an assessment. read doctor's history's and physicals. they use the same kinds of objective terms in describing things about the patient and sometimes they come up with some good stuff you'll want to use in the future! another very good place to find descriptors is in the various assessments links on this thread of allnurses:

i have to tell you that i spent much of my career developing my own assessment guideline. it started with one that was printed, laminated and placed in every chartback of one of the hospitals where i work. i swiped one and carried it on my clipboard for years adding little bits to it here and there. i often put it in front of me as i charted (narrative charting!) on patients. it had not only things that were a basic head to toe assessment, but safety items, ivs, calling the doctor for orders, follow up on lab tests and things to do with the call bell. stuff that you can sometimes forget to chart about. as i said, it's something i worked on over the years. i was looking for it a few weeks ago and i just can't find it. don't know what i did with it.

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I do have Taber's Cyclopedic Medical Dictionary on the PDA frm Nursing Central so will check and see if it it there~ thanks~

Yes, I have been working on a list but did not know if there were standard terms/words used like the NANDA, NOC, et. al

Since we were slammed so bad in clinic we thought we would try to find a standardized list to guide us~

Thanks again to all for your great help~

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Specializes in med/surg, telemetry, IV therapy, mgmt.
i do have taber's cyclopedic medical dictionary on the pda frm nursing central so will check and see if it it there~ thanks~

yes, i have been working on a list but did not know if there were standard terms/words used like the nanda, noc, et. al

since we were slammed so bad in clinic we thought we would try to find a standardized list to guide us~

thanks again to all for your great help~

no, i wouldn't say there is any official "standard terms/word" similar to what nanda uses. nanda, noc and nec are taxonomy language that was originally developed for ease and uniformity in computerized storage of the nursing care plan which is mandated by federal law and actually have nothing to do with charting of the nurses notes. what has happened has been that facilities that want their nurses to use nanda diagnosing have developed nursing forms that merge some nurses charting with the nanda nursing care plans to make things less confusing for the nurses. the medical record use for nanda diagnoses is for billing of advanced practitioner services, however.

as for charting of assessment terms, it is pretty common to say "breath sounds clear in all lobes", or "clear in all fields"; "respirations regular and unlabored"; "abdomen soft with bowel sounds present in all four quadrants"; "abdomen distended"; "skin warm and dry to touch".

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