Term
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Definition
| skillfully ending an interview so that the nurse and client feel satisfied that the purpose has been accomplished |
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Term
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Definition
| a systematic series of mental actions to analyze and interpret information about a client |
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Term
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Definition
| the pieces of subjective or objective information about a client or the signs and symptoms of disease |
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Term
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Definition
| the process of gathering data about a client's health status to identify the concerns and needs that can be treated or managed by nursing care |
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Term
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Definition
| participation in a conversation with a client in which the nurse attends to what the client says and has a part in helping the client clarify, elaborate and give additional pertinent information |
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Term
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Definition
| an indicator of the presence or existence of a problem or condition that represents a clients underlying health status |
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Term
| cardinal signs and symptoms |
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Definition
| the data of greatest significance in diagnosing a particular illness, disease or health problem |
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Term
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Definition
| factual information that can be aggregated to describe populations of clients |
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Term
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Definition
| all of the info that has been collected about a client and recorded in the health record as a baseline for the initial plan of care |
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Term
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Definition
| a question that calls for a specific short response from a client |
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Term
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Definition
| information that identifies and describes a client such as name, address, age, gender, religious affiliation, race or occupation |
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Term
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Definition
| a question that suggests a possible appropriate response from a client |
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Term
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Definition
| the process of attaching meaning to data or reaching a conclusion about data; based on a premise or proposition that supports or helps support a conclusion |
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Term
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Definition
| the least information allowable to be collected on every client entering an institution or being admitted to a particular service within the institution |
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Term
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Definition
| a narrative of a clients past health and health practices that focuses on information needed to plan nursing care |
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Term
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Definition
| objective data that are evidence of disease or dysfunction |
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Term
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Definition
| a brief exchange to establish the purpose, procedure, and nurse's role in the interview process |
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Term
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Definition
| a process of reasoning from understanding the whole without having systematically examined the parts |
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Term
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Definition
| a question designed to allow a client freedom in the manner of response |
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Term
| functional health patterns |
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Definition
| the positive and negative behavior a person uses to interact with the environment and maintain health |
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Term
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Definition
| any directly observable information about a client |
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Term
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Definition
| a planned series of questions designed to elicit information for a particular purpose |
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Term
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Definition
| 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 |
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Term
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Definition
| information that is provided by a client and cannot be directly observed |
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Term
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Definition
| substantiating or confirming the accuracy of the information against another source or by another method |
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Term
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Definition
| subjective information supplied by the client that describes characteristics of disease or dysfunction |
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Term
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Definition
| 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 |
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