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Assessing

Terms ch. 11 Kozier

TermDefinition
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.
Created by: mgibson3670