Term
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Definition
| The systematic and continuous collection, organization, validation, and documentation of data/information pg. 180 |
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Term
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Definition
head-to-toe approach (refering to physical assessments)
pg. 190 |
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Term
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Definition
| used in direct interviews, restrictive and typically requiring only "yes", "no", or short factual answers p. 187 |
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Term
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Definition
| subjective or objective data that can be directly observed by the nurse. What the client says or what the nurse can see, hear, feel, smell, or measure. pg. 195 |
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Term
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Definition
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Term
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Definition
| contains all the information about the client, to include nursing history, physical assessment, primary care providers history, phys. exam. pg. 183 |
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Term
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Definition
| highly structured and elicits specific information pg. 186 |
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Term
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Definition
| nurse's interpretations or conclusions based on cues pg. 195 |
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Term
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Definition
| planned communication or a conversation with a purpose pg. 186 |
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Term
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Definition
| closed, used in diretive interview, direct's clients answers pg. 187 |
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Term
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Definition
| question the client can answer without direction or pressure from the nurse pg. 187 |
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Term
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Definition
| rapport building interview, clients controls the direction and content pg. 187 |
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Term
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Definition
| systematic, rational process of planning and providing individualized nursing care. pg. 178 |
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Term
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Definition
| signs or overt data. Can be measured or tested against an accepted standard and are detectable by an observer. pg. 183 |
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Term
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Definition
| clients can explore, elaborate, discover, clarify, illustrate their thoughts or feelings. Associated with nondirective interviews. pg. 187 |
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Term
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Definition
| understanding between two or more people pg. 187 |
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Term
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Definition
| aka screening examination, brief review of essential functioning of various body parts or systems. pg. 190 |
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Term
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Definition
| aka review of systems, brief review of essential functioning of various body parts or systems. pg. 190 |
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Term
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Definition
| objective data, overt data. Can be measured or tested against accepted standard and are detectable by an observer. pg. 183 |
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Term
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Definition
| symptoms or covert data, apparent only to the person affected, can only be verified and described by the person. pg. 183 |
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Term
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Definition
| subjective data or covert data, apparent only to the person affected, can only be verified and described by the person. pg. 183 |
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Term
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Definition
"double-checking"
verify data to confirm it is factual
pg. 195 |
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