NSG 3160 EXAM 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.
First level priorities:
-Are those that are emergent, life threatening, and immediate, such as establishing an
airway or supporting breathing.
-ABC's (breathing
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).
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 effort between the patient and health care professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
Fourth level priorities:
-Collaborative problems.
-Get someone to help.
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.
4 types of health assessments:
-Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
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.
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?"
, 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.
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 interpreters, but they may not say everything that is needed to know about the
patient or what the patient says. Family is not the best interpreters.
Documenting:
Documentation is key if you don't document it didn't happen. It is important to document
everything to prevent mistakes and keep a general sense of communication between
providers and the healthcare team.
How to prioritize clinical findings:
Prioritize clinical findings by their threat to the patient's life. The MOST life threatening
finding will be the 1st priority due to its severity and ability to kill the patient.
Complete (Total Health) Database:
-A complete health history and a full physical examination. It describes the current and past
health state and forms a baseline against which ALL future changes can be measured to, it
yields the first diagnosis.
-This database is often collected in the primary care setting. (Pediatrics office, Family
practice clinics, etc.)
-In these setting you are the FIRST health professional to see the patient and have primary
responsibility for monitoring the person's health.
-Collecting this database is an opportunity to build and strengthen your relationship with the
patient.
-For the WELL patient, this database describes the person's:
-Health state
-Perception of health
-Strengths or assets such as : health maintenance behaviors, individual coping patterns,
support systems, current development tasks, and any risk factors or lifestyle changes.
-For the ILL patient, this database describes the person's:
-Health problems
-Perception of illness
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.
First level priorities:
-Are those that are emergent, life threatening, and immediate, such as establishing an
airway or supporting breathing.
-ABC's (breathing
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).
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 effort between the patient and health care professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
Fourth level priorities:
-Collaborative problems.
-Get someone to help.
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.
4 types of health assessments:
-Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
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.
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?"
, 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.
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 interpreters, but they may not say everything that is needed to know about the
patient or what the patient says. Family is not the best interpreters.
Documenting:
Documentation is key if you don't document it didn't happen. It is important to document
everything to prevent mistakes and keep a general sense of communication between
providers and the healthcare team.
How to prioritize clinical findings:
Prioritize clinical findings by their threat to the patient's life. The MOST life threatening
finding will be the 1st priority due to its severity and ability to kill the patient.
Complete (Total Health) Database:
-A complete health history and a full physical examination. It describes the current and past
health state and forms a baseline against which ALL future changes can be measured to, it
yields the first diagnosis.
-This database is often collected in the primary care setting. (Pediatrics office, Family
practice clinics, etc.)
-In these setting you are the FIRST health professional to see the patient and have primary
responsibility for monitoring the person's health.
-Collecting this database is an opportunity to build and strengthen your relationship with the
patient.
-For the WELL patient, this database describes the person's:
-Health state
-Perception of health
-Strengths or assets such as : health maintenance behaviors, individual coping patterns,
support systems, current development tasks, and any risk factors or lifestyle changes.
-For the ILL patient, this database describes the person's:
-Health problems
-Perception of illness
