NURS 3100 Exam 1
What are the 5 steps in the nursing process? - ANS-Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANS-collecting subjective and objective data
Diagnosis - ANS-analyzing data to make a collaborative nursing judgement
Planning - ANS-Determining outcome criteria and developing a plan
Implementation - ANS-carrying out the plan
Evaluation - ANS-Assessing whether outcome criteria have been met and revising the plan as
necessary
4 Basic types of assessments - ANS-Initial comprehensive, ongoing, focused, emergency
Initial Comprehensive (complete) - ANS-subjective and objective data
Ongoing (partial) - ANS-mini overview as a follow-up
Focused (problem-oriented) - ANS-specific concern
Emergency (rapid) - ANS-immediate and prompt
Proper techniques to prepare for assessment - ANS-review clients record, review client's status
with other team members, educate yourself about client's diagnosis and test performed, obtain
and organize needed materials
4 major steps in the assessment phase - ANS-1. Collection of subjective data
2. Collection of objective data
3. Validation of assessment data
4. Documentation of data
collection of subjective data - ANS-Biographical (name, age, religion)
• History of present health concern (physical symptoms related to each body system)
• Personal health history
,• Family history
• Health and lifestyle practices
• Review of systems
Collection of Objective Data - ANS-• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
Validation of assessment data - ANS--Ensure assessment isn't ended before all data is
collected
Documentation of data - ANS--Forms the database for all healthcare members
-Ensures valid conclusions can be made
ANALYSIS OF ASSESSMENT DATA/NURSING DIAGNOSIS (STEP 2 OF THE NURSING
PROCESS) - ANS-Identify abnormal data & strengths
• Cluster the data
• Draw inferences & identify problems
• Propose possible nursing diagnoses
• Check for defining characteristics of those diagnoses
• Confirm or rule out nursing diagnoses
• Document conclusions
Collection of subjective data - ANS-• Health History
• Phases of the Interview:
•1. Pre-introductory
•2. Introductory
•3. Working
•4. Summary and closing
Pre-introductory phase - ANS-Review the client's medical record (aka "chart-check")
INTRODUCTORY PHASE - ANS-• Introduce yourself to the client
• Explain the purpose of the interview
• Discuss the types of questions that will be asked
• Explain the reason for taking notes
• Assure the client that information will remain confidential
• Make sure the client is comfortable & has privacy
• Develop trust & rapport using verbal & nonverbal skills
WORKING PHASE - ANS-• Biographical data
, • Reasons for seeking care
• History of present health concern
• Past health history
• Family history
• Review of body systems
• Lifestyle & health practices
• Developmental level
SUMMARY AND CLOSING PHASE - ANS-• Summarize info obtained during the working
phase
• Validate problems & goals with the client
• Identify & discuss possible plans to resolve the problem with the client
• Ask if anything else concerns the client
• Ask if there are any further questions
Gerontologic variations - ANS-• Assess hearing acuity first
• Face the client
• Maintain trust, privacy, adequate time
Cultural variations - ANS-"Culture broker" and/or interpreter
REASONS FOR SEEKING CARE - ANS-• "What is your major health problem or concern at
this time?"
• "How do you feel about having to seek health care?"
• THE CHIEF COMPLAINT (should be in the client's own words; "I found a lump in my breast")
COMMUNICATION TO AVOID: - ANS-• Excessive or insufficient eye contact
• Distraction and distance
• Standing
• Biased or leading questions
• Rushing through the interview
• Reading the questions
COLDSPA - ANS-Character
Onset
Location
Duration
Severity
Pattern
Associated factors
Character - ANS-describe the character of the symptoms
Onset - ANS-when did this start
What are the 5 steps in the nursing process? - ANS-Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANS-collecting subjective and objective data
Diagnosis - ANS-analyzing data to make a collaborative nursing judgement
Planning - ANS-Determining outcome criteria and developing a plan
Implementation - ANS-carrying out the plan
Evaluation - ANS-Assessing whether outcome criteria have been met and revising the plan as
necessary
4 Basic types of assessments - ANS-Initial comprehensive, ongoing, focused, emergency
Initial Comprehensive (complete) - ANS-subjective and objective data
Ongoing (partial) - ANS-mini overview as a follow-up
Focused (problem-oriented) - ANS-specific concern
Emergency (rapid) - ANS-immediate and prompt
Proper techniques to prepare for assessment - ANS-review clients record, review client's status
with other team members, educate yourself about client's diagnosis and test performed, obtain
and organize needed materials
4 major steps in the assessment phase - ANS-1. Collection of subjective data
2. Collection of objective data
3. Validation of assessment data
4. Documentation of data
collection of subjective data - ANS-Biographical (name, age, religion)
• History of present health concern (physical symptoms related to each body system)
• Personal health history
,• Family history
• Health and lifestyle practices
• Review of systems
Collection of Objective Data - ANS-• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
Validation of assessment data - ANS--Ensure assessment isn't ended before all data is
collected
Documentation of data - ANS--Forms the database for all healthcare members
-Ensures valid conclusions can be made
ANALYSIS OF ASSESSMENT DATA/NURSING DIAGNOSIS (STEP 2 OF THE NURSING
PROCESS) - ANS-Identify abnormal data & strengths
• Cluster the data
• Draw inferences & identify problems
• Propose possible nursing diagnoses
• Check for defining characteristics of those diagnoses
• Confirm or rule out nursing diagnoses
• Document conclusions
Collection of subjective data - ANS-• Health History
• Phases of the Interview:
•1. Pre-introductory
•2. Introductory
•3. Working
•4. Summary and closing
Pre-introductory phase - ANS-Review the client's medical record (aka "chart-check")
INTRODUCTORY PHASE - ANS-• Introduce yourself to the client
• Explain the purpose of the interview
• Discuss the types of questions that will be asked
• Explain the reason for taking notes
• Assure the client that information will remain confidential
• Make sure the client is comfortable & has privacy
• Develop trust & rapport using verbal & nonverbal skills
WORKING PHASE - ANS-• Biographical data
, • Reasons for seeking care
• History of present health concern
• Past health history
• Family history
• Review of body systems
• Lifestyle & health practices
• Developmental level
SUMMARY AND CLOSING PHASE - ANS-• Summarize info obtained during the working
phase
• Validate problems & goals with the client
• Identify & discuss possible plans to resolve the problem with the client
• Ask if anything else concerns the client
• Ask if there are any further questions
Gerontologic variations - ANS-• Assess hearing acuity first
• Face the client
• Maintain trust, privacy, adequate time
Cultural variations - ANS-"Culture broker" and/or interpreter
REASONS FOR SEEKING CARE - ANS-• "What is your major health problem or concern at
this time?"
• "How do you feel about having to seek health care?"
• THE CHIEF COMPLAINT (should be in the client's own words; "I found a lump in my breast")
COMMUNICATION TO AVOID: - ANS-• Excessive or insufficient eye contact
• Distraction and distance
• Standing
• Biased or leading questions
• Rushing through the interview
• Reading the questions
COLDSPA - ANS-Character
Onset
Location
Duration
Severity
Pattern
Associated factors
Character - ANS-describe the character of the symptoms
Onset - ANS-when did this start
