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The Nursing Process -ANSWER Assessment
Diagnosis
Planning
Implementation
Evaluation
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
Comfort
Connection
Confirmation
Courtesy -ANSWER greet patients by preferred name
Introduce yourself and explain your role meet and acknowledge any visitors in a
patients room and learn their names
Comfort -ANSWER In a hospital setting perform any necessary comfort measures before
beginning the interview
Connection -ANSWER establish eye contact and sit at eye level if possible during an
interview
Do not dominate a discussion or assume that you know the nature of a patients
problems.
Start with open ended questions
listen and be attentive
use your observation skills
respect silence and be flexible 'let the patients needs concerns or questions guide your
follow up questions
Confirmation -ANSWER Ask the patient to summarize the discussion so there are no
uncertanties
Be open to further clarification or discussion
Phases of an Interview -ANSWER -orientation and setting an agenda
-working phase
-terminating an Interview
Orientation and setting an agenda -ANSWER Set the scene! Your aim is to set an
agenda for how you will gather information about a patient current chief concerns or
problems
-explaining your purpose
-asking patient for his or her list of concerns/problems
-nothing that all information will be confidential
working phase of interview -ANSWER start an assessment or a nursing health history
with open ended questions that allow patients to describe more clearly their concerns or
problem
Terminating an interview -ANSWER Summarize your discussion with a patient and check
for accuracy of the information collected