NSG 3160 Exam 1
1. Know how to collect data and the pitfalls to avoid when interviewing the
patient and collecting data.: Communication is going to carry the interview; you should
build and establish rapport with the patient. Show the patient that you are interested and concerned
about their health to gain trust from the patient. If the patient sees this, they are more likely to open
and share vital information regarding their health and health concerns. This will allow us to understand
and assess the patient at a better standpoint. Communication can be Verbal or Non-verbal. Verbal
communication is spoken words, vocalizations, tone of voice. Non-verbal communication is body
language - gestures, facial expressions, posture, eye contact, foot tapping, touch,
where you sit to talk to them. Non-verbal is more of an unconscious form of communication and is a
reflection of true feelings. Be aware of the messages you send a receive to the patient. Think about how
you may be interpreted to the patient.
2. First level priorities:: -Are those that are emergent, life threatening, and immediate, such
establishing
an airway or supporting breathing.
-ABC's (breathing
3. Second level priorities:: -Are those that are next in urgency- those requiring your prompt
intervention to forestall further deterioration.
-Mental status change, acute pain, acute urinary elimination problems, untreated medical problems,
abnormal lab values, risks of infection, or risk to safety or security. (Pain, pee, poop).
4. Third level priorities:: -Are those that are important to the patient's health but can be attended
to after
more urgent health problems are addressed. Interventions to treat these problems may require a
collaborative ettort between the patient and health care professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
5. Fourth level priorities:: -Collaborative problems.
-Get someone to help.
6. Evidence based practice:: Health care is ever changing, Evidence Based Practice are the
best techniques used to treat patients. Findings are implemented into daily practice. EBP is multi-faced
and reflects holistic practice. EBP encompasses of the integration of research evidence, clinical expertise,
clinical knowledge (physical assessment), and patient values and preferences. Clinical decision making
depends on all four factors: the best evidence from critical review of research literature, the patient's
own experience and expertise, and physical examination and assessment.
, NSG 3160 Exam 1
7. 4 types of health assessments:: -Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
, NSG 3160 Exam 1
8. Six steps of nursing diagnosis:: 1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
-The nursing process is the standard of practice in nursing. It is a process that allows practitioners to
move back and forth while caring for the needs of complex patients. Nurses use this process to
formulate a nursing diagnosis and plan care, establish goals, implement the goals for healing, and
reassessing the patient to ensure goals are met. If goals are not met, reassess the patient and maybe
think about formulating a new nursing diagnosis plan of care.
9. Use of open-ended questions:: -Open ended questions are a useful technique to use as
they provide
a way for the patient to be more open and talk about their concerns. Open-ended questions are
seeking narrative information. It is unbiased, the person is free to answer in their own way. The patient
is encouraged to respond in paragraphs and give a spontaneous account. EXPRESSION!! Make eye
contact and actively listen. Typically, the patient will provide an answer and look at you for direction on
whether to continue. "Tell me about your headaches"
-Direct/Closed-ended questions ask for specific information. They elicit a one- or two-word answer,
such as yes/no questions are vague and do not get the point across and do not let the patient express
their concerns as they should. They are less likely to express themselves if they are given yes/no
questions. They limit the patient's answer. "Where are your headaches located?"
10. Distractions- Note taking, cellphones, etc.:: Excessively taking notes and not
making eye
contact with your patient while they are speaking will tell the patient that you are uninterested or not paying
attention to what they are telling you. This can also distract the patient as they are focused on you and what
you are doing. Excessive leg shaking can also distract the patient. If you are expecting a phone call or to
be taken out of the room during the interview let the patient know ahead of time. Do not look at your
watch excessively.
11. Use of an interpreter:: Interpreters must be used when working with patients that you
both do not speak
the same language. The best interpreter to use of the one provided by the facility. Family members can be
1. Know how to collect data and the pitfalls to avoid when interviewing the
patient and collecting data.: Communication is going to carry the interview; you should
build and establish rapport with the patient. Show the patient that you are interested and concerned
about their health to gain trust from the patient. If the patient sees this, they are more likely to open
and share vital information regarding their health and health concerns. This will allow us to understand
and assess the patient at a better standpoint. Communication can be Verbal or Non-verbal. Verbal
communication is spoken words, vocalizations, tone of voice. Non-verbal communication is body
language - gestures, facial expressions, posture, eye contact, foot tapping, touch,
where you sit to talk to them. Non-verbal is more of an unconscious form of communication and is a
reflection of true feelings. Be aware of the messages you send a receive to the patient. Think about how
you may be interpreted to the patient.
2. First level priorities:: -Are those that are emergent, life threatening, and immediate, such
establishing
an airway or supporting breathing.
-ABC's (breathing
3. Second level priorities:: -Are those that are next in urgency- those requiring your prompt
intervention to forestall further deterioration.
-Mental status change, acute pain, acute urinary elimination problems, untreated medical problems,
abnormal lab values, risks of infection, or risk to safety or security. (Pain, pee, poop).
4. Third level priorities:: -Are those that are important to the patient's health but can be attended
to after
more urgent health problems are addressed. Interventions to treat these problems may require a
collaborative ettort between the patient and health care professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
5. Fourth level priorities:: -Collaborative problems.
-Get someone to help.
6. Evidence based practice:: Health care is ever changing, Evidence Based Practice are the
best techniques used to treat patients. Findings are implemented into daily practice. EBP is multi-faced
and reflects holistic practice. EBP encompasses of the integration of research evidence, clinical expertise,
clinical knowledge (physical assessment), and patient values and preferences. Clinical decision making
depends on all four factors: the best evidence from critical review of research literature, the patient's
own experience and expertise, and physical examination and assessment.
, NSG 3160 Exam 1
7. 4 types of health assessments:: -Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
, NSG 3160 Exam 1
8. Six steps of nursing diagnosis:: 1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
-The nursing process is the standard of practice in nursing. It is a process that allows practitioners to
move back and forth while caring for the needs of complex patients. Nurses use this process to
formulate a nursing diagnosis and plan care, establish goals, implement the goals for healing, and
reassessing the patient to ensure goals are met. If goals are not met, reassess the patient and maybe
think about formulating a new nursing diagnosis plan of care.
9. Use of open-ended questions:: -Open ended questions are a useful technique to use as
they provide
a way for the patient to be more open and talk about their concerns. Open-ended questions are
seeking narrative information. It is unbiased, the person is free to answer in their own way. The patient
is encouraged to respond in paragraphs and give a spontaneous account. EXPRESSION!! Make eye
contact and actively listen. Typically, the patient will provide an answer and look at you for direction on
whether to continue. "Tell me about your headaches"
-Direct/Closed-ended questions ask for specific information. They elicit a one- or two-word answer,
such as yes/no questions are vague and do not get the point across and do not let the patient express
their concerns as they should. They are less likely to express themselves if they are given yes/no
questions. They limit the patient's answer. "Where are your headaches located?"
10. Distractions- Note taking, cellphones, etc.:: Excessively taking notes and not
making eye
contact with your patient while they are speaking will tell the patient that you are uninterested or not paying
attention to what they are telling you. This can also distract the patient as they are focused on you and what
you are doing. Excessive leg shaking can also distract the patient. If you are expecting a phone call or to
be taken out of the room during the interview let the patient know ahead of time. Do not look at your
watch excessively.
11. Use of an interpreter:: Interpreters must be used when working with patients that you
both do not speak
the same language. The best interpreter to use of the one provided by the facility. Family members can be
