NR 509 Notes

1. Assessment- point of entry in an ongoing a. Subjective data and objective data that is used to make a database for the purpose of judgment or diagnosis 2. Diagnostic reasoning applies the scientific method a. Data is prioritized by urgency of signs and symptoms b. Medical diagnosis are used to evaluate the cause or etiology of disease c. Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state. d. The process of analyzing health data and drawing conclusions to identify diagnoses i. Attending to cues ii. Formulating hypotheses iii. Gathering Data iv. Evaluating each hypothesis 3. EBP provides the best care with the most current treatment available. 4. Critical thinking and the diagnostic procedure a. First-level priority problems: life threatening and immediate needs b. Second level priority problems: requires prompt intervention to prevent further deterioration and may include a mental status change, acute pain or abnormal laboratory value c. Third Level priority problems: less urgent problems d. Collaborative problems: involves multiple disciplines 5. EVB Assessment 6. Collecting four types of Data a. Complete database b. Focused or problem centered c. Follow-up database d. Emergency database 7. Expanding the concept of health a. Holistic health model including mind, body, and spirit as interdependent and functioning as a whole. Defined as the absence of disease. b. Health promotion and disease prevention 8. Culture and genetics a. Obtaining a heritage assessment helps gather data that are accurate and meaningful and can guide culturally sensitive and appropriate care. Chapter 3: The interview 1. Data a. Subjective data- what the person says about themselves b. Objective data- what you obtain through physical exam 2. Communication a. Nonverbal vs verbal communication and body language are important in sending and receiving messages in the communication. 3. Internal Factors a. Liking others b. Empathy c. The ability to listen i. Active listening ii. Passive Listening d. Self-awareness i. Personal biases ii. Prejudices iii. Stereotypes 4. External Factors a. Ensure Privacy b. Refuse Interruptions c. Physical Environment i. Temperature, lighting, noise, distractions, personal space d. Dress e. Note taking i. Effects the eye contact and can shift attention away from the patient communication f. Electronic Health Record (HER) 5. Techniques of communication a. Introducing the interview- addressing the person b. The working phase i. Gathering data- use appropriate questions that are open ended to allow for free resonse. c. Closed or Direct Questions i. Elicit a short , one to two word answers ii. Help to gain specific information left out of the personal narrative d. Verbal responses-Assisting the Narrative i. 9 types of verbal responses 1. Facilitation, silence, reflection, empathy, clarification involve reactions to facts and feelings a. Responses are based on the frame of reference b. Client lead 2. Confrontation, interpretation, explanation, summary are expressions of thought and feelings a. Practitioner lead e. Ten traps of interviewing i. Providing false assurance or reassurance ii. Giving unwanted advice iii. Using authority iv. Using avoidance language v. Distancing vi. Using professional jargon vii. Using leading or biased questions viii. Talking too much ix. Interrupting x. Using why questions f. Nonverbal skills i. Physical Appearance ii. Posture iii. Gestures iv. Facial Expressions v. Touch g. Closing the interview- asking if there is anything else or any questions ism appropriate end giving for the person to have a final opportunity for self-expression. 6. Communicating with different ages a. The infant (Birth to 12 months) i. No formal interview but can assess for nonverbal cues b. The Toddler (12 to 36 months) i. On to two-word responses will be given ii. Keep it simple and give one direction at a time c. The preschooler (3-6) i. Telegraphic sentences- containing essential words ii. Direct, concrete, literal and set in present tense communication. iii. Imaginative thoughts and responses iv. Use play to explain d. The school-age child (7-12) i. Understanding of others viewpoints ii. Objective and realistic iii. Wants to know how things work iv. Able to decenter- consider all points of view v. Can add to own history during the interview e. The Adolescent i. Puberty is a time of dramatic physiologic change including growth, sex characteristics and self-concept. ii. Capable of mature actions, but can revert back on childhood responses at times Chapter 4: The complete health hi