COMPLETE ANSWERS VERIFIED
◉ subjective data. Answer: what pt says. things that are not
apparent to another person or can only be felt or perceived by the pt
◉ objective data. Answer: observable and measurable data that can
be seen heard or felt by someone other than the pt. vital signs- a
number or a lab
◉ sources for obtaining information on an assessment. Answer:
Patient is number one source, family and significant others, patient
record, other health care professionals, nursing and healthcare
literature
◉ what is a nursing interview?. Answer: planned communication to
obtain a history
◉ what are the phases of a nursing- interview. Answer: Prepatory
phase-read current and past records
Introduction-introduce self, give title and purpose of interview
Working Phase- data gathering
, Clarify and verify- ask additional questions about conditions, meds,
anything that is unclear, if they have been seen for this condition,
any tx or meds currently being used prescription or otc
Termination- Is there anything else you would like us to know that
will help us plan your care
◉ inference. Answer: judgment-ask questions to validate
◉ documentation. Answer: enter data asap, if it isn't recorded, it
didn't happen, summarize, use pt's own words, avoid non-specific
terms
◉ health assessment. Answer: gather information about pt's health
status, identify strengths and actual and potential health problems,
pt's response to the condition, TO ESTABLISH A BASE FOR THE
NURSING PROCESS
◉ components of health assessment. Answer: health hx and physical
assessment
◉ preparing for the physical exam. Answer: consider the needs of
the patient, explain the process, ask pt to change into a gown and
empty bladder, answer questions directly and honestly, gather
necessary supplies, provide privacy, and a warm quiet room with
adequate lighting