Front | Back |
Systematic and continuous collection, organization, validation, and documentation of data.
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Assessing
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Head to toe
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Cephalocaudal
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Generally required only a yes or no answer
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Closed questions
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Subjective or objective data that can be observe by the nurse
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Cues
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Information is known as
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Data
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All information about a client
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Database
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Highly structured, elicits specific information
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Directive interview
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Nurse's interpretation or conclusion based on cues
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Inferences
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Planned communication
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Interview
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Usually closed, and directs the client's answer
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Leading questions
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When a client can answer without direction or pressue, is open-ended
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Neutral question
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Rapport-building interview
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Nondirective interview
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Detectable by an observer, can be measured or tested
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Objective data
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An understanding between two or more people
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Rapport
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Brief screening examination
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Review of systems
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