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Client Assessment
Client Assement
| Term | Definition |
|---|---|
| Active Listening | participation in a conversation with a client in which the nurse attend to what the client says and has a part in helping the client clarify, elaborate, and give additional pertinent information |
| Active Processing | a systematic series of mental actions to analyze and interpret information about a client |
| Assessment | the process of gathering data about a client's health status to identify the concerns and needs health status to identify the concerns and needs that can be treated or manages by nursing care |
| Biographical data | information that identifies and describes a client, such as name, address, age, gender, religious affiliation, race, or population |
| Cardinal signs & symptoms | the data of greatest significance in diagnosing a particular illness, disease, or health problem |
| chief complaint | the problem that causes a client to seek health services, call the doctor, or request a visit from a nurse; a description of what a client thinks is the problem |
| closed question | a question that calls for a specific short response from a client |
| cue | an indicator of the presence of existence of a problem or condition that represents a client's underlying health status |
| data | pieces of subjective or objective information about a client or the signs and symptoms of disease |
| database | all of the information that has been collected about a client and recorded in the health record as a baseline for the initial place of care |
| demographic data | factual information that can be aggregated to describe populations of clients |
| functional health patterns | the positive and negative behavior a person uses to interact with the environment and maintain health |
| inference | the process of attaching meaning to data or reaching a conclusion about data; bases on a premise or proposition that supports or helps support a conclusion |
| interview | a planned series of questions designed to elicit information for a particular purpose |
| intuition | a process of reasoning from understanding the whole without having systematically examined the parts |
| leading question | a question that suggests a possible appropriate response from a client |
| minimum data set | the least information allowable to be collected on every client entering an institution or being admitted to a particular service within the institution |
| nursing history | a narrative of a client's past health and health practices that focuses on information needed to plan nursing care |
| objective data | any directly observable information about a client |
| open-ended question | a question designed to allow a client freedom in the manner of response |
| orientation phase | a brief exchange to establish the purpose, procedure, and nurses role in the interview process |
| signs | objective data that are evidence of disease or dysfunction |
| subjective data | information that is provided by a client and cannot be directly observed |
| symptoms | subjective information supplied by the client that describes characteristics of disease or dysfunction |
| termination | skillfully ending an interview so that the nurse and client feel satisfied that the purpose has been accomplished |
| validation | substantiating or confirming the accuracy of the information against another source or by another method |
| working phase | a phase of the interview process during which a client and nurse work together to review the client's health history and establish potential and actual problems that will be addressed as part of the care plan |
Created by:
dortega52
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