GROUP COLLABORATION
STUDY GUIDE
EXAM III
DO NOT TYPE IN THIS DOCUMENT
COPY AND PASTE TO A BLANK WORD DOCUMENT
Review Client Situation on pages 13-18 of Doenges- Nursing Care Plan book (10th)
o 9th Edition: Pg 20-24
o Review ALL elements of Mr. R.S assessment together as a group
o Discuss in detail the subjective and objective data for each system
o Become very familiar with Mr. R.S. assessment
o Questions will be asked on the exam about Mr. R.S.
THE TOPICS BELOW ARE NOT RELATED TO MR. R.S ASSESSMENT.
THESE ARE TOPICS THAT WILL BE ON THE EXAM
Understand the nursing process steps (Pages 11-12; 17-18)
o ASSESSMENT; gather information about the pt condition
o DIAGNOSE; identify the pt problem
o PLAN; set goals of care and desired outcomes and identify appropriate nursing
actions
o IMPLEMENTATION; perform the nursing actions identified in planning
o EVALUATION; Determine if goals and expected outcomes are achieved
ASSESMENT
The collection, review, and analysis of data make up the process of assessment
Two stages of assessment:Collection of information from a primary source (a patient) and
secondary sources
The interpretation and validation of data to determine whether more data are needed or
the database is complete.
Use critical thinking during assessment
Knowledge; underlying disease process, normal growth and development, normal
psychology, normal assessment findings
- Health promotion
- Assessment skills
- Communication skills
Experience; Previous patient care experience
, - Validation of assessment findings
- Observation of assessment techniques
Attitude; Perseverance, fairness, integrity, confidence, creativity
Standards; ANA scope and Standards of Nursing Practice Specialty Standards of practice,
Intelectial standards of measurement
Types of Assessments
Patient Centered Interview; conducting during a nursing history.
Periodic Assessment; Conducted during ongoing contact with pt
Physical examination; Conducted during a nursing history and at any time a pt present
symptoms.
Types of Data
Subjective
Patients’ verbal descriptions of their health problems
Includes patient feelings, perceptions, and self-reported symptoms
Objective
Findings resulting from direct observation
When you collect objective data, apply critical thinking intellectual standards so that you
can correctly interpret your findings.
Assessment Data Sources
Patient
Family caregivers and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse’s experience
The Nurse-Patient Relationship in Assessment
Effective communication
Foundation for creating nurse-patient relationships.
Trust building
Presence
Rounding
The Patient-Centered Interview
Motivational interviewing
Interview preparation
Communication skills
Courtesy
Comfort
Connection
Confirmation
,Phases of the Interview ; Orientation and setting an agenda,
Working phase—collecting data. Interview techniques, Observation, Open-ended questions,
Direct closed-ended questions, Leading questions, Back channeling, Probing, Interpret,
Termination phase
Nursing Health History
Key component of a comprehensive assessment
Covers all health dimensions
Cultural Considerations
Cultural competence
Involves self-awareness, reflective practice, and knowledge of a patient’s core cultural
background.
Cultural humility
Requires you to recognize your own knowledge limitations and cultural perspective and thus be
open to new perspectives.
Show your patients respect and understand their individual needs and differences; do not impose
your own attitudes, biases, and beliefs.
Professionalism in History Taking
To display professionalism and a caring approach during an interview, look at the patient and not
the computer screen.
Use the computer if you must but position it in a way that does not distract from your focus on
the patient.
Components of the Nursing Health History
Biographical information
Chief concern or reason for seeking care
Patient expectations
Present illness or health concerns
Past health history
Family history
Psychosocial history
Spiritual health
Review of systems
Observation of patient behaveor
Diagnostic and laboratory data
Data Documentation
Record the results of the nursing health history and physical examination in a clear, concise
manner using appropriate terminology.
Baseline to identify a patient’s health problems, to plan and implement care, and to evaluate a
patient's response to interventions
Record all observations succinctly
Record any subjective information by using quotation marks.
, The nursing process organizes your approach to delivering nursing care. To
provide care to your patients, you will need to incorporate nursing process
and:
interview process.
The Assessment Process
Data collection
Use information about a patient’s needs to adapt your data collection.
Interpretation
Critically interpret assessment data to determine whether abnormal findings are present.
Cues and inferences
Validation
Comparison of data with another source to determine data accuracy
The assessment process; A male pt is in bed looking uncomfortable; pt presents with discomfort
in surgical area
CUES; Lies still with arms along sides; tense
States has not turned for some time
Reports pain a 7 on a scale of 0-10
INFERENCE
Pain is severe
Pain limits pt ability to move and reposition self
QUESTIONS;
Are you having pain?
Show me where the pain is located?
Rate the pain on a scale of 0-10
When is the last time you turned?
Did you get up in a chair last night?
May I look at your incision?
- Know the severity of the pain acute or chronic
- ACUTE PAIN CAN SHOW RECOVERY
- Limited mobility?
- Is infection developing
Concept Mapping
Organize assessment data
Placing all the cues together into the clusters that form patterns leads you to the next step of the
nursing process, nursing diagnosis
The nurse's assessment covers the health perception- health management pattern,
which is a patient's self-report of how he or she manages his or her health and his or her
knowledge of preventive health practices.
An inference is your judgment or interpretation of cues such as the shuffling gait and
reduced leg strength.
STUDY GUIDE
EXAM III
DO NOT TYPE IN THIS DOCUMENT
COPY AND PASTE TO A BLANK WORD DOCUMENT
Review Client Situation on pages 13-18 of Doenges- Nursing Care Plan book (10th)
o 9th Edition: Pg 20-24
o Review ALL elements of Mr. R.S assessment together as a group
o Discuss in detail the subjective and objective data for each system
o Become very familiar with Mr. R.S. assessment
o Questions will be asked on the exam about Mr. R.S.
THE TOPICS BELOW ARE NOT RELATED TO MR. R.S ASSESSMENT.
THESE ARE TOPICS THAT WILL BE ON THE EXAM
Understand the nursing process steps (Pages 11-12; 17-18)
o ASSESSMENT; gather information about the pt condition
o DIAGNOSE; identify the pt problem
o PLAN; set goals of care and desired outcomes and identify appropriate nursing
actions
o IMPLEMENTATION; perform the nursing actions identified in planning
o EVALUATION; Determine if goals and expected outcomes are achieved
ASSESMENT
The collection, review, and analysis of data make up the process of assessment
Two stages of assessment:Collection of information from a primary source (a patient) and
secondary sources
The interpretation and validation of data to determine whether more data are needed or
the database is complete.
Use critical thinking during assessment
Knowledge; underlying disease process, normal growth and development, normal
psychology, normal assessment findings
- Health promotion
- Assessment skills
- Communication skills
Experience; Previous patient care experience
, - Validation of assessment findings
- Observation of assessment techniques
Attitude; Perseverance, fairness, integrity, confidence, creativity
Standards; ANA scope and Standards of Nursing Practice Specialty Standards of practice,
Intelectial standards of measurement
Types of Assessments
Patient Centered Interview; conducting during a nursing history.
Periodic Assessment; Conducted during ongoing contact with pt
Physical examination; Conducted during a nursing history and at any time a pt present
symptoms.
Types of Data
Subjective
Patients’ verbal descriptions of their health problems
Includes patient feelings, perceptions, and self-reported symptoms
Objective
Findings resulting from direct observation
When you collect objective data, apply critical thinking intellectual standards so that you
can correctly interpret your findings.
Assessment Data Sources
Patient
Family caregivers and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse’s experience
The Nurse-Patient Relationship in Assessment
Effective communication
Foundation for creating nurse-patient relationships.
Trust building
Presence
Rounding
The Patient-Centered Interview
Motivational interviewing
Interview preparation
Communication skills
Courtesy
Comfort
Connection
Confirmation
,Phases of the Interview ; Orientation and setting an agenda,
Working phase—collecting data. Interview techniques, Observation, Open-ended questions,
Direct closed-ended questions, Leading questions, Back channeling, Probing, Interpret,
Termination phase
Nursing Health History
Key component of a comprehensive assessment
Covers all health dimensions
Cultural Considerations
Cultural competence
Involves self-awareness, reflective practice, and knowledge of a patient’s core cultural
background.
Cultural humility
Requires you to recognize your own knowledge limitations and cultural perspective and thus be
open to new perspectives.
Show your patients respect and understand their individual needs and differences; do not impose
your own attitudes, biases, and beliefs.
Professionalism in History Taking
To display professionalism and a caring approach during an interview, look at the patient and not
the computer screen.
Use the computer if you must but position it in a way that does not distract from your focus on
the patient.
Components of the Nursing Health History
Biographical information
Chief concern or reason for seeking care
Patient expectations
Present illness or health concerns
Past health history
Family history
Psychosocial history
Spiritual health
Review of systems
Observation of patient behaveor
Diagnostic and laboratory data
Data Documentation
Record the results of the nursing health history and physical examination in a clear, concise
manner using appropriate terminology.
Baseline to identify a patient’s health problems, to plan and implement care, and to evaluate a
patient's response to interventions
Record all observations succinctly
Record any subjective information by using quotation marks.
, The nursing process organizes your approach to delivering nursing care. To
provide care to your patients, you will need to incorporate nursing process
and:
interview process.
The Assessment Process
Data collection
Use information about a patient’s needs to adapt your data collection.
Interpretation
Critically interpret assessment data to determine whether abnormal findings are present.
Cues and inferences
Validation
Comparison of data with another source to determine data accuracy
The assessment process; A male pt is in bed looking uncomfortable; pt presents with discomfort
in surgical area
CUES; Lies still with arms along sides; tense
States has not turned for some time
Reports pain a 7 on a scale of 0-10
INFERENCE
Pain is severe
Pain limits pt ability to move and reposition self
QUESTIONS;
Are you having pain?
Show me where the pain is located?
Rate the pain on a scale of 0-10
When is the last time you turned?
Did you get up in a chair last night?
May I look at your incision?
- Know the severity of the pain acute or chronic
- ACUTE PAIN CAN SHOW RECOVERY
- Limited mobility?
- Is infection developing
Concept Mapping
Organize assessment data
Placing all the cues together into the clusters that form patterns leads you to the next step of the
nursing process, nursing diagnosis
The nurse's assessment covers the health perception- health management pattern,
which is a patient's self-report of how he or she manages his or her health and his or her
knowledge of preventive health practices.
An inference is your judgment or interpretation of cues such as the shuffling gait and
reduced leg strength.
