Chapter 11 Kozier
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26 terms
Terms | Definitions |
|---|---|
 data collection | process of gathing information about a clients health status |
| database | contains all the information about a pt, including the health history |
| assessing | systematic and continous collection, organization and documentation of data |
| nursing process | systematic, rational method of planning and providing individualized nursing care |
| subjective data | symptoms, apparent only to the person affected |
| objective data | signs, are detectable by an observer or can be measured or tested |
| constant data | data that does not change over time, such as race or blood type |
| variable data | changes, frequently, rarely or anything in between, includes bp, age, hr ect |
| primary source of data | Patient |
| secondary source of data | all sources other than Pt, should be validated if possible |
| observe | gather data by using the senses by using concious deliberate skills |
| interview | planned communication or conversation with a purpose |
| directive interview | highly structuers and elicits specific information |
| nondirective interview | rapport-building interview |
| rapport | understanding between 2 people |
| closed ended questions | restrictive and require yes or no answers or short factual replies |
| open ended questions | invite Pt to elaborate, clarify their thoughts and feelings |
| neutral question | client can answer without direction or pressure from nurse, open ended |
| leading question | normally closed question, directs the clients answer and restricts answer |
| proxemics | study of use of space |
| cephalocaudal | head to toe approach of examination-head, neck, thorax, abdomen, extremeties, ends at toes |
| screening examination | review of systems, brief review of essential functions of various body parts |
| pattern | a sequence of recurring behavior |
| validation | the act of "double checking" or verifying data to confirm that it is accurate |
| cues | subjective or objective data that can be directly observed by the nurse |
| inferences | the nurses interpretation or conclusions made based on cues |
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