Ch. 16 (nursing assessment) OBJECTIVES

Question 1

2. Explain the process of data collection.

Answer 1

Cluster cues, make inferences, and identify emerging patterns/potential problem areas.
Information comes from:
- The patient, through interview, observations, and physical exams
- Family members or significant others reports and response to interviews
-other members of the healthcare team
- medical record information (patient history, lab work, x-ray film results, multidisciplinary consultations)
- Scientific literature (evidence about assessment techniques and standards)

Question 2

3. Differentiate between subjective and objective data.

Answer 2

1. Subjective data:
    Your patient's verbal descriptions of 
    their health problems.
2. Objective data:
    Observations or measurements of 
    the patient's health status.

Question 3

4. Describe the methods of data collection:

Answer 3

1. Patient-centered interviews
2. The nursing health history
3. Physical examination
4. Results of lab/diagnostic tests

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Question 4

5. Discuss the process of conducting a patient-centered interview.

Answer 4

1. Setting the stage:
    Greet patient using full name, 
    introduce yourself and explain your
    role, remove any barriers to privacy
2. Set an agenda:
    Gather information about the 
    patient's current chief concerns/
    problems and set an agenda. Ask 
    patient to list their concerns/
    problems
3. Collect the assessment/nursing 
    health history:
    begin with open-ended questions, 
    use attentive listening, stay focused 
    and orderly
4. Terminating the interview:
    Summarize your discussion with the 
    patient, check for accuracy, make a 
    closing statement, end in a friendly 
    manner

Question 5

6. Describe the components of a nursing history.

Answer 5

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1. Biographical information-
Age, address, occupation/working
status, marital status, source of
healthcare, types of insurance
2. Reason for seeking healthcare-
Record the clients response in
quotations to indicate subjective
response
3. Patient expectations-
Important to assess the patient’s
understanding of why he/she is
seeking healthcare. They usually
have expectations of receiving
information about their treatment
and prognosis and plan of care for
returning home; expect relief of pain,
other symptoms, caring expressed
by healthcare providers
4. Present illness/health concerns-
a) Collect essential and relevant data
about the symptoms and their
effects on the patient’s health.
b) assess these factors:
-Location – where is a symptom
located
-Onset/duration
-Precipitating factors – what makes
symptoms worse
-Relieving factors
-Quality- have patient describe
what the symptom feels like
-Concomitant symptoms-are there
other symptoms along with the
primary symptom
5. Health history
6. Family history
7. Environmental history
8. Psychosocial history
9. Spiritual health
10. Review of symptoms
11. Documentation of history findings

Question 6

7. Explain the differences among comprehensive, problem-oriented, and focused assessments.

Answer 6

A comprehensive assessment

Question 7

8. Explain the relationship between data interpretation and validation.

Answer 7

p. 217
While you are interpreting assessment information, you need to also validate the collected information to avoid making incorrect inferences.

For example, “I noticed that you have been crying. Can you tell me about it?” In order to determine the real reason for the patient’s crying.

Question 8

1. Discuss the relationship between critical thinking and nursing assessment

Answer 8

p. 207
Critical thinking is a vital part of assessment.
While gathering data about a patient, you synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking standards and attitudes, and use standards of practice to direct your assessment in a meaningful and purposeful way