Page 81 - Modul English Communication In Nursing

anta syifaa'an laa yughaadiru saqoman. Ameen. May Allah grant you good health and
strength, Insha’Allah. Wassalamualaikum, Mr. Fajar.”
Mr. Fajar : “Wa alaikum assalam, Nurse Aisha. Ameen. Thank you for your care and guidance.”

Match each vocabulary word from the nursing care plan with its correct definition. Review the
b.
dialogue for hints about each term’s meaning and usage if you need help.

Nursing Care Plan a. The systematic evaluation of a patient’s health status through
observation, examination, and patient history.
Assessment b. A written document that outlines the patient’s nursing diagnosis,
interventions, expected outcomes, and the evaluation process.
Nursing Diagnosis c. A clinical judgment about individual, family, or community responses
to actual or potential health problems or life processes.
Nursing Intervention d. Any treatment, based upon clinical judgment and knowledge, that a
nurse performs to enhance patient outcomes.
Patient Outcomes e. Measurable changes in health status that result from the
implementation of nursing interventions.
Goals f. Specific, measurable outcomes that the nursing care plan aims to
achieve within a certain timeframe.
Implementation g. Goals that are Specific, Measurable, Achievable, Relevant, and Time-
bound, providing clear direction for patient care.
Evaluation h. The phase where the nursing interventions outlined in the care plan
are put into action.
Collaboration i. The process of assessing the effectiveness of the nursing interventions
and determining if the goals of the care plan have been met.
Documentation j. The exchange of information between healthcare providers, patients,
and families regarding the care plan and patient progress.
k. Information and instructions provided to the patient to help them
understand their health condition and management plan.
l. Working in partnership with other healthcare professionals to deliver
comprehensive care based on the nursing care plan.
m. The written record of the nursing process, including assessments,
nursing diagnoses, interventions, and outcomes.

pg. 71