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Client Assessment

Client Assement

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