Approach to identify, diagnose, and treat human responses to health and illness
Assessment
Collection, verification, and analysis of data (1st step in nursing process)
Database
The client's perceived needs, health problems, and responses
Cue
Information that was obtained through the use of the senses
Inference
Your judgment or interpretation of cues
List Gordon's 11 functional health patterns.
1. health perception-health management pattern2. nutritional-metabolic pattern3. elimination pattern4. activity-exercise pattern5. sleep-rest pattern6. cognitive-perceptual pattern7. self-perception-self-concept pattern8. role-relationship pattern9. sexuality-reproductive pattern10. coping-stress tolerance pattern11. value-belief pattern
What are the two primary sources of data
Subjective Data & Objective Data
Subjective Date
Client's verbal descriptions of health problems
Objective Data
Observations of measurement of a clients health status
Identify the variety of sources where data can be obtained.
a. clientb. family and significant others c. health care team d. medical records e. literature
During the initial interviewing process, nurses have the opportunity to...
a. introduce yourself, explain your role b. establish a caring therapeutic relationship c. get insight about the client's concerns d. determine the client's goals and expectations e. obtain cues about which parts of the data collection phase require further investigation
Protected health information includes demographic data that relates to:
a. an individual's past, present, or future physical or mental health or condition b. the provision of health care to the individual c. the past, present, or future payment for provision of health care to the individual
Nursing health history includes...
Data about the client's current level of wellness, review of systems, family history, sociocultural history, spiritual history, and mental and emotional reactions to illness
Open-ended questions
prompts clients to describe a situation in more than one or two words
Back channeling
active listening prompts
Closed-ended questions
limit the client's answers to one or two words
Biographical information
factual demographic data about the client
Reasons for seeking health care
Client's perception
Clients expectations
What is important to the client
Present illness / Health Concerns
Essential and relevant data about the nature and onset of symptoms
Health history
Health care experiences and current health habits and lifestyle patterns
Family history
Data about the immediate and blood relatives
Environmental history
Client's home and work, focusing on determining the client's safety
Psychosocial history
Reveals the client's support systems, coping mechanisms
Spiritual history
Represents the totality of one's being
Review of systems
Systematic method for collecting data from all body systems
Data Validation
Is the comparison of data with another source to determine data accuracy
Data analysis
Involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a conclusion about the client's responses to a health problem
Identify some common practices related to documentation, the last part of a complete assessment.
Timely, thorough, and accurate; record all observations; pay attention to facts and be descriptive; record objective information in accurate terminology; do not generalize or form judgments
The interview technique that is most effective in strengthening the nurse-client relationship by demonstrating the nurse's willingness to hear the client's thoughts is?
Open-ended question
While obtaining a health history, the nurse asks Mr. jones if he has noted any change in his activity tolerance. This is an example of which interview technique?
Direct Question
Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique?
Problem-solving
Review of systems (ROS)
Systematic method for collecting data on all body systems.
The information obtained in a review of systems (ROS) is? (objective or subjective)
Subjective
The Five Steps to the Nursing Process
assessment, diagnosis, planning, implementation, and evaluation.
Taking one proposition as a given and guessing that another proposition follows.
Nursing
Diagnosis and treatment of human responses to actual or potential health problems.
Functional health patterns
Method for organizing assessment data based on the level of client function in specific areas (e.g., mobility).
Interview
Type of communication with a client that is initiated for a specific purpose and focused on a specific content area.
Standards
Measure or guide that serves as a basis for comparison when evaluating similar phenomena or substances.