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Assessing
Terms ch. 11 Kozier
Term | Definition |
---|---|
Assessing | The systematic and continuous collection, organization, validation, and documentation of data. |
Cephalocaudal | Head-to-toe approach begins the examination at the head. |
Closed Questions | Are used in a directive interview, are restricted and generally require only "yes" or "no" or short factual answers giving specific information. |
Cues | Subjective or objective data that can be directly observed by the nurse, that is; what the client say or the nurse uses her senses to aquire. |
Data | Information. |
Database | Contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostics tests, and material contributed by other health profe |
Directive Interview | Highly structured and elicits specific information. |
Inferences | Are a nurse's interpretation or conclusions based on on the cues a nurse observes. |
Interview | A planned communication or a conversation with a purpose. |
Leading Questions | Usually a closed-question, used in directive interviews, directs the clients answer. |
Neutral Question | A question the client can answer without direction or pressure from the nurse, is open-ended and used in nondirective interviews. |
Nondirective Interview | A rapport building interview, the nurse allows the client to control the purpose, subject matter, and pacing. |
Nursing Process | A systematic, rational method of planning and providing individualized nursing care. |
Objective Data | The signs or overt data. |
Open-ended Questions | Associated with the nondirective interview, invite client to discover and explore, elaborate, clarify, or illustrate their thoughts or feeling. |
Rapport | An understanding between two or more people. |
Review of Systems | Review of essential functioning of various body parts or systems. |
Screening Examination | Also called a review of systems, is a brief review of essential functioning of various body parts or systems. |
Signs | Detectable by an observer or can be measured or tested against an accepted standard. |
Subjective Data | The symptoms or covert data. |
Symptoms | Apparent only to the person affected and can be described or verified only by that person. |
Validation | The act of "double checking" or verifying the data to confirm that it is actual and factual. |