NURB 3060 Exam 1 Study Guide | Nursing
Process, Health Assessment, Interview
Techniques, COLDSPA, Communication &
Documentation.
What is the first step in the nursing process?
assessment
How do nurses collect data about a patient's health?
In a systematic, ongoing process
What sources are used to collect patient health history or data?
- patient
- patient's family
- other healthcare providers
- environment
Assessment
collection of data
Initial Assessment
large and detailed
Subjective Data
- things that comes out the the patient's mouth
- sensations or symptoms, feeling, perceptions, desires, preferences, beliefs, ideas, values, and
personal information that are reported by the patient and verified by the patient
What are the major areas of subjective data?
- biographical info
- history of illness and personal health
- past and current behavior
- family history
Objective Data
,- data directly or indirectly observed
- patient did not say this information
Major Sources of Objective Data?
- physical assessment
- patient's record
- measurements
- testing result
What are the four types of assessments?
- initial comprehensive
- ongoing or partial
- focused or problem oriented assessment
- emergency assessment
Initial Comprehensive Assessment
Subjective data about the client's perception of illness, past history, family history, lifestyle and
health practices
Ongoing or Partial Assessment
- Occurs after the comprehensive assessment
- Looking for a baseline
- Occurs when the patient is on the floor
Focused or Problem Oriented Assessment
Thorough assessment of a particular client problem and does not cover areas not related to the
problem
Emergency Assessment
rapid assessment performed in life-threatening situations
Steps of the Health Assessment
- steps will overlap
1. collection of subjective data
2. collection of objective data
3. validation of objective data
4. documentation of data
Purpose of the interview
, - establish rapport and a trusting relationship
- gathers information about the developmental. psychological, physiologic, sociocultural, and
spiritual needs of the client
What are the four phases of the interview?
1. pre-introductory
2. introductory
3. working
4. summary/closing
Pre Introductory Assessment
- occurs before the initial meeting
- receiving health history or receiving data from a previous healthcare provider
Introductory Assessment
- initial meeting/assessment
- explain that you are taking notes, assure confidentiality, eye level with the patient.
- if the patient is in pain, treat the pain first
- full attention is on the patient
Working Assessment
- nuts and bolts
- where you collect the data and assess the body
- listen, observe, and think critically
- verbal and non-verbal clues
Summary/Closing Assessment
validation of information, goal setting, discussion of care, rules, asks for any concerns and
question
Nonverbal Communication
- communication that relies on appearance, demeanor, facial expression, attitude, silence, and
listening
Types of Verbal Communication
- open ended questions
- laundry list
- closed ended questions
- rephrasing
Process, Health Assessment, Interview
Techniques, COLDSPA, Communication &
Documentation.
What is the first step in the nursing process?
assessment
How do nurses collect data about a patient's health?
In a systematic, ongoing process
What sources are used to collect patient health history or data?
- patient
- patient's family
- other healthcare providers
- environment
Assessment
collection of data
Initial Assessment
large and detailed
Subjective Data
- things that comes out the the patient's mouth
- sensations or symptoms, feeling, perceptions, desires, preferences, beliefs, ideas, values, and
personal information that are reported by the patient and verified by the patient
What are the major areas of subjective data?
- biographical info
- history of illness and personal health
- past and current behavior
- family history
Objective Data
,- data directly or indirectly observed
- patient did not say this information
Major Sources of Objective Data?
- physical assessment
- patient's record
- measurements
- testing result
What are the four types of assessments?
- initial comprehensive
- ongoing or partial
- focused or problem oriented assessment
- emergency assessment
Initial Comprehensive Assessment
Subjective data about the client's perception of illness, past history, family history, lifestyle and
health practices
Ongoing or Partial Assessment
- Occurs after the comprehensive assessment
- Looking for a baseline
- Occurs when the patient is on the floor
Focused or Problem Oriented Assessment
Thorough assessment of a particular client problem and does not cover areas not related to the
problem
Emergency Assessment
rapid assessment performed in life-threatening situations
Steps of the Health Assessment
- steps will overlap
1. collection of subjective data
2. collection of objective data
3. validation of objective data
4. documentation of data
Purpose of the interview
, - establish rapport and a trusting relationship
- gathers information about the developmental. psychological, physiologic, sociocultural, and
spiritual needs of the client
What are the four phases of the interview?
1. pre-introductory
2. introductory
3. working
4. summary/closing
Pre Introductory Assessment
- occurs before the initial meeting
- receiving health history or receiving data from a previous healthcare provider
Introductory Assessment
- initial meeting/assessment
- explain that you are taking notes, assure confidentiality, eye level with the patient.
- if the patient is in pain, treat the pain first
- full attention is on the patient
Working Assessment
- nuts and bolts
- where you collect the data and assess the body
- listen, observe, and think critically
- verbal and non-verbal clues
Summary/Closing Assessment
validation of information, goal setting, discussion of care, rules, asks for any concerns and
question
Nonverbal Communication
- communication that relies on appearance, demeanor, facial expression, attitude, silence, and
listening
Types of Verbal Communication
- open ended questions
- laundry list
- closed ended questions
- rephrasing
