Identify the two steps of the nursing assessment - ✔✔ 1. Collection of information from primary source (patient) and secondary sources (family care g... [Show More] iver, family or friend, health professionals, chart)
2. Interpretation and validation of data to determine whether more data is needed or database is complete
Discuss the two primary types of data (subjective and objective) - ✔✔ Subjective: Patient's verbal descriptions of their health problems. Include: feelings, perceptions and self reported symptoms
Objective: Findings resulting from direct observations or measurements. Including what you see, hear and touch
Objective data is measured on the basis of... - ✔✔ an accepted standard (aka known scales e.g: kg, lbs, in, cm, etc. etc.)
Identify the variety of sources where data can be obtained (5) - ✔✔ 1. Patient
2. Family caregivers and significant others - provide primary source for infants or children, critically ill adults, and patients who have intellectual disabilities or cognitive impairments. They can also confirm findings from the patient and/or identify important health patterns in the patient (eating and sleeping habits, etc. etc.)
3. Health care team - change of shift or patient hand off information
4. Medical records - medical history, lab reports, diagnostic test results, current physical findings and a health care provider's treatment plan
5. Other - Educational, military, employment records & scientific literature -- offer prior illnesses and immunization info
The best source of data will always come from - ✔✔ a patient that is alert and able to answer questions
What source of information does a patient need to consent for healthcare workers to acquire and why? - ✔✔ Education, military and employment records
HIPAA protects access
List the four communication skills that are needed to effectively communicate. - ✔✔ 1. Courtesy
2. Comfort
3. Connection
4. Confirmation
Information about courtesy - ✔✔ Ask how the patient would like to be addressed.
Introduce yourself and explain your role the first time you meet.
Ensure confidentiality of info patient chooses to share.
Meet and acknowledge visitors in patient's room and learn names and roles.
Sit down next to patient.
Take notes sparingly, remember key words
Information about comfort - ✔✔ Ensure patient is comfortable. Provide necessary comfort measures before beginning interview.
Maintain patient privacy.
Select location that is quiet and free of interruptions. Set aside 10-15 minute period.
Avoid overtiring patient.
Information about connection - ✔✔ Make a good first impression. Don't stare at screen.
Begin with open ended questions.
Allow patient to fully describe their symptoms without interrupting.
Let patient's needs, concerns, ro questions guide your follow-up questions
Information about confirmation - ✔✔ Ask patient to summarize the discussion so there are no uncertainties
During an interview, observational techniques are used. Briefly explain observation. - ✔✔ Watching a patient's verbal and nonverbal behaviors. Also observing a patient's level of functions: the physical, developmental, psychological & social aspects of everyday living
During an interview, open-ended questions are used. Briefly explain what an open-ended question is. - ✔✔ They give a patient discretion about the extent of their answer. This type of question does not presuppose an answer. Allows the patient to actively describe their health status
During an interview, leading questions might be used. Why are leading questions bad? - ✔✔ They limit the amount of info the patient will give you.
During an interview, back channeling techniques are used. Briefly explain what back channeling is - ✔✔ Active listening prompts such as "all right," "go on," or "uh huh," that encourage the patient to give more detail
During an interview, probing techniques are used. Briefly describe what probing is - ✔✔ "digging" into a patient's story by asking open ended questions ("anything more you can tell me?" or "what else is bothering you?")
During an interview, direct close-ended questions may be used. Briefly describe what direct close-ended questions are - ✔✔ Questions that require only a short answer and clarify previous information. These questions only require one or two words to answer (e.g. "how often does the diarrhea occur?" or "do you have pain or cramping?")
A nurse completes the following steps during her shift of care. Which are steps of the nursing assessment? (Select all that apply.)
1. The review of patient data in the medical record
2. Confirming a patient's self-report of abdominal pain by inspecting the abdomen
3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift
4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration
5. Conducting an interview of a family caregiver - ✔✔ 1, 2, 4, 5
Assessment is the collection of a comprehensive set of data about a patient and recognizing and identifying patterns that begin to reflect the meaning of a patient's response to health problems. The types of assessment are: patient-centered interview, periodic assessments, and physical examination.
Match the assessment activity with A. problem focused or B. Comprehensive
1. Assessment conducted at beginning of a nurse's shift
2. Review of a patient's chief complaint
3. Completion of admitting history at time of patient admission to a hospital
4. Completion of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home. - ✔✔ 1. A
2. A
3. B
4. B [Show Less]
