II Glossary
Activities of daily living: Daily basic tasks fundamental to everyday functioning (e.g., hygiene, elimination, dressing, eating, ambulating/moving).
Belief: Something accepted as true with a sense of certainty.[1]
Body image: A mental picture of one’s body related to appearance and function.[2]
Care partners: Family and friends who are involved in helping to care for the patient.
Chief complaint: The reason a patient is seeking health care during a visit to a clinic or on admission to a health care facility.
Cultural safety: The creation of safe spaces for patients to interact with health professionals without judgment or discrimination.
Dysuria: Discomfort or pain on urinating.
Elimination: Refers to the removal of waste products through the urine and stool.
Functional health: The patient’s physical and mental capacity to participate in activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Gender expression: Characteristics in appearance, personality, and behavior, culturally defined as masculine or feminine.[3]
Gender identity: One’s basic sense of being male, female, or other gender.[4]
Health history: The process of using directed interview questions to obtain symptoms and perceptions about a patient’s illness or life condition. The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.
Instrumental activities of daily living: Complex daily tasks that allow patients to function independently such as managing finances, paying bills, purchasing and preparing meals, managing one’s household, taking medications, and facilitating transportation.
LGBTQ: An acronym standing for lesbian, gay, bisexual, transgender, and queer is an umbrella term that generally refers to a group of people who are diverse with regard to their gender identity and sexual orientation. There are expanded versions of this acronym.[5]
Main health care needs: Term used to classify what needs the patient feels are most important to address after admission to a health care agency.
Medication reconciliation: A comparison of a list of current medications with a previous list and is completed at every hospitalization and clinic visit.
Melena: Dark, tarry-looking stool due to the presence of digested blood.
Mental health: A state of well-being in which every individual realizes their own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community.[6]
Mobility: A patient’s ability to move around (e.g., sit up, sit down, stand up, walk).
Nursing: Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care of individuals, families, groups, communities, and populations in recognition of the connection of all humanity.[7]
Objective data: Information observed through your sense of hearing, sight, smell, and touch while assessing the patient.
Primary source of data: Information obtained directly from the patient.
Secondary source of data: Information from the patient’s chart, family members, or other health care team members.
Self-concept: Knowledge a person has about themselves that makes up who they are (i.e., their identity).
Self-esteem: A person’s self-evaluation of their self-concept as being worthy or unworthy.
Sexual orientation: The preferred term used when referring to an individual’s physical and/or emotional attraction to the same and/or opposite gender.[8]
Sign: Objective data found by the nurse or health care provider when assessing a patient.
Spirituality: A way of living that comes from a set of meanings, values, and beliefs that are important to a person.[9]
Subjective data: Information obtained from the patient and/or family members that offers important cues from their perspectives.
Symptom: Subjective data that the patient reports, such as “I feel dizzy.”
Value: An accepted principle or standard of an individual or group.[10]
Voiding: Medical terminology used for urinating.
- Gordon, M. (2008). Assess notes nursing: Nursing assessment and diagnostic reasoning for clinical practice. F. A. Davis Company. ↵
- Gordon, M. (2008). Assess notes nursing: Nursing assessment and diagnostic reasoning for clinical practice. F. A. Davis Company. ↵
- The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf downloaded from https://www.jointcommission.org/resources/patient-safety-topics/health-equity/#t=_Tab_StandardsFAQs&sort=relevancy ↵
- The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf downloaded from https://www.jointcommission.org/resources/patient-safety-topics/health-equity/#t=_Tab_StandardsFAQs&sort=relevancy ↵
- The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf downloaded from https://www.jointcommission.org/resources/patient-safety-topics/health-equity/#t=_Tab_StandardsFAQs&sort=relevancy ↵
- This work is a derivative of The Complete Subjective Health Assessment by Lapum, St-Amant, Hughes, Petrie, Morrell, and Mistry licensed under CC BY-SA 4.0 ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- The Joint Commission. (2011). Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf downloaded from https://www.jointcommission.org/resources/patient-safety-topics/health-equity/#t=_Tab_StandardsFAQs&sort=relevancy ↵
- Gordon, M. (2008). Assess notes nursing: Nursing assessment and diagnostic reasoning for clinical practice. F. A. Davis Company. ↵
- Gordon, M. (2008). Assess notes nursing: Nursing assessment and diagnostic reasoning for clinical practice. F. A. Davis Company. ↵