Professional nurse's approach for selecting, organizing and delivering appropriate nursing care to a patient.
How would you describe the critical thinking approach to nursing assessment?
Assessment is used to establish a database about the patients perceived needs, health problem and response to these problems. Critical thinking is a vital part of assessment. It allows you to see the big picture when you form conclusions or make decisions about a patients health condition.
What are the two steps to nursing assessment?
1. Collection of data from a primary source (the patient) and secondary sources (family, friends, medical record, health professionals, literature)
2. Interpretation and validation of all data as a basis for developing nursing diagnosis, identifying collaborative problems and developing a plan of individualized care.
What is the process of data collection?
Collection and verification of data from a primary source (the patient) and secondary sources (family, friends, medical record, health professionals, literature)
What are the two primary sources of data?
Subjective: Information verbalized or stated by the client. Subjective data: what pt/family says; Symptoms; Client's feelings; Statement
Objective: Observable and measurable information. Remember to include your senses: smell, hearing, touch and sight. Objective data: what I see/observe as nurse; Signs/ overt clues; Observations; Standard assessment; Laboratory and diagnostic testing
How do the following contribute to data collection?
a. The client: best source of information
b. The family and significant others: Primary sources or children, critically ill adults and mentally handicapped, disoriented or unconscious. They are also secondary sources.
c. The health care team:
d. The medical records: offers
e. The nurses experience:
How would you define the nursing interview?
A health interview is a structured interaction between you and the patient. The rules governing this interaction should be clearly outlined and agreed on by you and the patient at the start of the interview. Your mutual goal is the patient's optimal health.
What information is gathered during the nursing interview?
Information on pts Physical & Developmental state eg normal functioning, pathological changes caused by illness, trauma or developmental crisis
Emotional: pts behavioral responses to change in health and patterns of living eg moon, perceptions, body image, self-concept and attitudes about sexuality
Intellectual: includes intellectual performance, problem-solving ability, educational level, communication patterns and attention span.
Social: environmental, cultural, ethnic or social patterns that affect the preent and future level of wellness; can get info on life goals and values and religious practices
Spiritual: religious practices
How would you define these phases of a therapeutic relationship? Pg 315
a. Orientation phase: nurse and client become acquainted; Goal: Establish trust; Formulate contract for intervention
b. Working phase: When nurse and patient work together to solve problem and accomplish goals; Goal: Promote client change
c. Termination phase: During the ending of the relationship; Goal: Evaluate goal attainment; Ensure therapeutic closure
What are the elements of good interview techniques?
Open-ended questions: prompts patients to describe a situation in more than one or two words. It lead to a discussion in which patients actively describe their health status. Strengthens relationship with patient because it shows you want to hear patients thoughts and feelings.
Back Channeling: includes active listening prompts such as all right, go on and uh-huh. Indicate you heard what patient says and interested in hearing the full story. Encourages patient to give more details.
Probing: encourage a full description without trying to control the direction the story takes. Probe with more open-ended questions. Be observant.
Close-ended questions: these questions limit answers to one or two words. They are used to clarify previous information or provide additional information. Helps you get specific information about health problems such a symptoms, precipitating factors or relief measures.
Why is it important to understand cultural diversity when assessing your client?
So that you can offer better care within differing value systems and act with respect and understanding without imposing your own attitudes and beliefs
How would you name and describe the various components of a comprehensive nursing health history?
Biographic data: factual demographic data about patient; age, address, occupation and working status, marital status, source of health care, types of insurance.
Reasons for seeking health care: Information you gather when you initially set an agenda during patient centered interview. Learn patients chief complaint.
Patient expectations: assessment of patient expectations, not the same as reason for seeking medical care. Failure to identify patients expectations results in poor patient satisfaction.
Present illness or health concern: if ill, collect essential and relevant data about symptoms and effects on patients health.
Past health history: information in patients health history provide data on patients health care experiences and current health habits. Has he ever been hospitalized, been injured, had surgery? Get medication hx including herbal and OTC drugs. Allergies to food, drugs, latex or contact agents (like soap). Alcohol, tobacco, caffeine or recreational drug use
Family health history: about immediate and blood relatives. Assesses risk for illness of a genetic or familial nature and identify areas of health promotion and illness prevention. Info of family structure, interaction, support and function.
Review of body systems (ROS): systematic approach of collecting patients self-reported data on all body systems. Ask about normal functioning of each body system and any noted changes
Environmental history: provides data of patients home and working environment with focus on determining the patients safety.
Psychosocial history: reveals patients support system which often includes spouse, children and other family members and close friend. Methods patient use to cope with stress can be helpful when planning nursing interventions.
Spiritual health: life experiences and events shape a persons spirituality. Spiritual dimension represents the totality f ones being and is difficult to assess quickly. Review with patients their beliefs about life, their source for guidance in acting on beliefs and relationships they have with family in exercising their faith. Assess rituals and religious practices.
What information is gained during the physical examination?
Height, weight, vital signs, head-to-toe examination of all body systems
Why is it important to observe the clients behavior?
The information adds depth to objective database; you learn to determine if data obtained by observation matches what patient tells you eg if pt says she has no concern about upcoming diagnostic test but has poor eye contact, shakiness and restlessness the verbal and nonverbal data conflict.
Why is it necessary to consider diagnostic and lab results when assessing your client?
It provides further information of alterations or problems identified during the nursing health history and physical exam.
How does the nurse apply critical thinking to the successful analysis and interpretation of client data?
Why is accurate data documentation important?
If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. If info I not specific the reader is left with only general impressions. Observing and recording patient status are legal and professional responsibilities.