QUESTIONS WITH SOLUTIONS GRADED A+
◉ Assessment. Answer: 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. Answer: information collected from the
patient through interviews, observations, and physical examinations
◉ Secondary data collection. Answer: 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. Answer: information that you obtain through use of the
senses
◉ Inference. Answer: your judgement or interpretation of these cues
◉ Different types of assessments. Answer: Patient centered
interview
,Physical examination
periodic assessment
◉ Comprehensive patient history. Answer: 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,".
Answer: 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. Answer: -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. Answer: Offers
a holistic framework for assessment of any health problem provides
for a comprehensive review of a patients health care problems
,◉ Subjective Data. Answer: your patient's verbal descriptions of
their health problems
◉ Objective Data. Answer: observations or measurements of a
patient's health status
◉ Sources of Data. Answer: Patient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse's experience
◉ Patient data. Answer: 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. Answer: in cases of severe
illness or emergency situations, families are often the only source of
information for health care providers
, ◉ Health care Team data. Answer: every member of the health care
team is a source of information for identifying and verifying
essential information about a patient
◉ Medical Records data. Answer: is a valuable tool for checking the
consistency and similarities of data with your personal observations
◉ Other records and the scientific literature data. Answer: 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. Answer: 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. Answer: 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. Answer: Courtesy