The Nursing Process Correct Ans - Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment Correct Ans - the deliberate and systematic collection
of information about a patient to determine the patients current and past
health and functional status and his or her present and past coping
patterns. Includes two steps:
Collection of information and Analysis of data
Primary data collection Correct Ans - information collected from
the patient through interviews, observations, and physical examinations
Secondary data collection Correct Ans - information collected from
family members or significant others reports and response to interviews,
other members of the health care team, medical records, scientific and
medical literature
Cue Correct Ans - information that you obtain through use of the
senses
Inference Correct Ans - your judgement or interpretation of these
cues
Different types of assessments Correct Ans - Patient centered
interview
Physical examination
periodic assessment
Comprehensive patient history Correct Ans - 1) Use structured
database format on the basis of an accepted theoretical framework or
practice standard
2) Problem Focused
,Watson and Foster's model of "The Attending Caring Nurse," Correct
Ans - Supports a comprehensive assessment of caring needs and
concerns from a patients frame of reference. It uses caring theory as a
guide of identifying caring needs and assessing the meaning of both
subjective and objective concerns
Nola Pender's Health Promotion Model Correct Ans - -several key
factors that provide primary motivation for individuals to adopt behaviors
that maintain and improve their health
- the goal is for the individual to move toward a balanced state of positive
health and well-being
Gordeons Model of 11 Functional health patterns Correct Ans -
Offers a holistic framework for assessment of any health problem provides
for a comprehensive review of a patients health care problems
Subjective Data Correct Ans - your patient's verbal descriptions of
their health problems
Objective Data Correct Ans - observations or measurements of a
patient's health status
Sources of Data Correct Ans - Patient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse's experience
Patient data Correct Ans - usually your best source of information.
Patients who are conscious, alert and able to answer questions without
cognitive impairment provide the most accurate information.
Family and Significant Others data Correct Ans - in cases of severe
illness or emergency situations, families are often the only source of
information for health care providers
,Health care Team data Correct Ans - every member of the health
care team is a source of information for identifying and verifying essential
information about a patient
Medical Records data Correct Ans - is a valuable tool for checking
the consistency and similarities of data with your personal observations
Other records and the scientific literature data Correct Ans - HIPPA
allows health care providers the ability to share protected information as
long as they use reasonable safeguards
The review of recent nursing, medical, and pharmacological literature
about a patients illness completes a patients assessment database
Nurse's Experience data Correct Ans - Through clinical experience
a nurse observes other patients; recognizes clinical changes; and learns the
types of questions to ask, choosing only the questions that will give the
most useful information.
Patient Center Interview Correct Ans - this is relationship based
and is an organized conversation focused on learning about the well and
the sick as they seek care. This becomes the basis for forming trust and
effective long term therapeutic relationships with patients.
Effective communication skills Correct Ans - Courtesy
Comfort
Connection
Confirmation
Courtesy Correct Ans - greet patients by preferred name
Introduce yourself and explain your role meet and acknowledge any
visitors in a patients room and learn their names
Comfort Correct Ans - In a hospital setting perform any necessary
comfort measures before beginning the interview
Connection Correct Ans - establish eye contact and sit at eye level if
possible during an interview
Do not dominate a discussion or assume that you know the nature of a
patients problems.
, Start with open ended questions
listen and be attentive
use your observation skills
respect silence and be flexible 'let the patients needs concerns or questions
guide your follow up questions
Confirmation Correct Ans - Ask the patient to summarize the
discussion so there are no uncertanties
Be open to further clarification or discussion
Phases of an Interview Correct Ans - -orientation and setting an
agenda
-working phase
-terminating an Interview
Orientation and setting an agenda Correct Ans - Set the scene! Your
aim is to set an agenda for how you will gather information about a patient
current chief concerns or problems
-explaining your purpose
-asking patient for his or her list of concerns/problems
-nothing that all information will be confidential
working phase of interview Correct Ans - start an assessment or a
nursing health history with open ended questions that allow patients to
describe more clearly their concerns or problem
Terminating an interview Correct Ans - Summarize your discussion
with a patient and check for accuracy of the information collected
Give your patient a clue that the interview is coming to an end
Interview Techniques Correct Ans - Observation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions
Observation Correct Ans - gathering of information through
nonverbal behavior, appearance, and interaction with the environment, you
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