NUFT 202 exam 2
The Nursing Process - ANSAssessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANSthe 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 - ANSinformation collected from the patient through interviews,
observations, and physical examinations
Secondary data collection - ANSinformation 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 - ANSinformation that you obtain through use of the senses
Inference - ANSyour judgement or interpretation of these cues
Different types of assessments - ANSPatient centered interview
Physical examination
periodic assessment
Comprehensive patient history - ANS1) 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," - ANSSupports 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 - ANS-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 - ANSOffers a holistic framework for
assessment of any health problem provides for a comprehensive review of a patients health
care problems
Subjective Data - ANSyour patient's verbal descriptions of their health problems
Objective Data - ANSobservations or measurements of a patient's health status
Sources of Data - ANSPatient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse's experience
Patient data - ANSusually 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 - ANSin cases of severe illness or emergency situations,
families are often the only source of information for health care providers
Health care Team data - ANSevery member of the health care team is a source of information
for identifying and verifying essential information about a patient
Medical Records data - ANSis a valuable tool for checking the consistency and similarities of
data with your personal observations
Other records and the scientific literature data - ANSHIPPA 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 - ANSThrough 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 - ANSthis 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 - ANSCourtesy
Comfort
Connection
, Confirmation
Courtesy - ANSgreet patients by preferred name
Introduce yourself and explain your role meet and acknowledge any visitors in a patients room
and learn their names
Comfort - ANSIn a hospital setting perform any necessary comfort measures before beginning
the interview
Connection - ANSestablish 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 - ANSAsk the patient to summarize the discussion so there are no uncertanties
Be open to further clarification or discussion
Phases of an Interview - ANS-orientation and setting an agenda
-working phase
-terminating an Interview
Orientation and setting an agenda - ANSSet 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 - ANSstart 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 - ANSSummarize your discussion with a patient and check for
accuracy of the information collected
Give your patient a clue that the interview is coming to an end
Interview Techniques - ANSObservation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions
The Nursing Process - ANSAssessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANSthe 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 - ANSinformation collected from the patient through interviews,
observations, and physical examinations
Secondary data collection - ANSinformation 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 - ANSinformation that you obtain through use of the senses
Inference - ANSyour judgement or interpretation of these cues
Different types of assessments - ANSPatient centered interview
Physical examination
periodic assessment
Comprehensive patient history - ANS1) 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," - ANSSupports 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 - ANS-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 - ANSOffers a holistic framework for
assessment of any health problem provides for a comprehensive review of a patients health
care problems
Subjective Data - ANSyour patient's verbal descriptions of their health problems
Objective Data - ANSobservations or measurements of a patient's health status
Sources of Data - ANSPatient
Family and significant others
Health care team
Medical records
Other records and the scientific literature
Nurse's experience
Patient data - ANSusually 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 - ANSin cases of severe illness or emergency situations,
families are often the only source of information for health care providers
Health care Team data - ANSevery member of the health care team is a source of information
for identifying and verifying essential information about a patient
Medical Records data - ANSis a valuable tool for checking the consistency and similarities of
data with your personal observations
Other records and the scientific literature data - ANSHIPPA 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 - ANSThrough 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 - ANSthis 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 - ANSCourtesy
Comfort
Connection
, Confirmation
Courtesy - ANSgreet patients by preferred name
Introduce yourself and explain your role meet and acknowledge any visitors in a patients room
and learn their names
Comfort - ANSIn a hospital setting perform any necessary comfort measures before beginning
the interview
Connection - ANSestablish 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 - ANSAsk the patient to summarize the discussion so there are no uncertanties
Be open to further clarification or discussion
Phases of an Interview - ANS-orientation and setting an agenda
-working phase
-terminating an Interview
Orientation and setting an agenda - ANSSet 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 - ANSstart 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 - ANSSummarize your discussion with a patient and check for
accuracy of the information collected
Give your patient a clue that the interview is coming to an end
Interview Techniques - ANSObservation
Open-ended questions
Leading questions
Back channeling
Direct closed-ended questions
