Nursing Process part 2 Flashcards
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 diagnostic tests, and material contributed by other health personnel.
Database
Information provided by the patient’s family and friends. (An interpretation of the client’s support people)
Secondary subjective data
Include information documented by various healthcare professionals.
Client record
Types of client record
Medical records
Records of therapies
Laboratory records
Are often a source of a client’s present and past health and illness patterns. These records can provide nurses with information about the client’s coping behaviors, health practices, previous illnesses, and allergies.
Medical records
Provided by other health professionals, such as social workers, nutritionists, dietitians, or physical therapists, help the nurse obtain relevant data not expressed by the client.
Record of therapies
Also provide pertinent health information
Laboratory records
Serve as other potential sources of information about a client’s health
Verbal reports
Principal methods used to collect data
Observing
Interviewing
Examining
Two aspects of observing
Noticing data
Selecting, organizing, and interpreting data
Involves distinguishing data in a meaningful manner
Observing
The nurse asks the client specific questions to collect information related to the client’s problem.
Focused interview
Is an understanding between two or more people.
Rapport
A combination of ____________ and ______________ approaches is usually appropriate during the information-gathering interview.
directive, nondirective
Types of interview questions
Closed or open ended
Neutral or leading
