Term
|
Definition
| the process of collecting, organizing, validating, and recording data (information) about a client's health status |
|
|
Term
|
Definition
| proceeding in the direction from head to toe |
|
|
Term
|
Definition
| restrictive question requiring only a short answer |
|
|
Term
|
Definition
| any piece of information or data that influences decisions |
|
|
Term
|
Definition
|
|
Term
|
Definition
| all information about a client, includes nursing health history and physical assessment, physician's history, physical examination, and laboratory and diagnostic test results |
|
|
Term
|
Definition
| a highly structured interview that uses closed questions to elicit specific information |
|
|
Term
|
Definition
| interpretations or conclusions made based on cues or observed data |
|
|
Term
|
Definition
| a planned communication; a conversation with a purpose |
|
|
Term
|
Definition
| a question that influences the client to give a paticular question |
|
|
Term
|
Definition
| a question that does not direct or pressure a client to answer in a certain way |
|
|
Term
|
Definition
| an interview using open-ended questions and empathetic responses to build rapport and learn client concerns |
|
|
Term
|
Definition
| a systematic rational method of planning and providing nursing care |
|
|
Term
|
Definition
| (signs) information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled |
|
|
Term
|
Definition
| questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic |
|
|
Term
|
Definition
| a relationship between two or more people of mutual trust and understanding |
|
|
Term
|
Definition
| SEE Screening Examinations |
|
|
Term
|
Definition
| (review of systems) a brief review of essential functioning of various body parts or systems |
|
|
Term
|
Definition
|
|
Term
|
Definition
| (symptoms) data that are apparent only to the person affected; can be described or verified only by that person |
|
|
Term
|
Definition
|
|
Term
|
Definition
| the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data |
|
|
