Chapter 1 & 3- Evidence Based Assessment & The Interview Flashcards
Assessment phase includes what things??
Subjective data + Objective data + patient’s record, and laboratory studies from the database
Subjective = “________” ?
Symptoms
Objective = “_________” ?
Signs
Subjective Data definition?
Patient’s statements, concerns, & sensations
- Ex: pain * Whatever our patient's tell us*
Objective Data definition?
Observable or Measurable by you
- Ex: Vital signs
Heart/Lung sounds
Blood work
Change in skin color
Looks more fatigued than usualSteps of the Nursing Process?
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
Four types of Health Assessment?
- Complete health assessment
- Episodic or problem-centered assessment
- Follow-up assessment
- Emergency assessment
What is an example of a Episodic or problem-centered assessment?
Shift assessment
What is an example of a Follow-up assessment?
Giving someone an Analgesic for pain and then going back to check
Assessment definition?
The collection of data about a person’s health
The ___________ is the best chance to gain an understanding of the patient’s beliefs, concerns, and perception of their individual health state?
Interview
The Interview allows for what?
Allows for compilation of subjective data and initial awareness of objective data
During The Interview the health care provider establishes what with the patient?
Establishes trust and builds rapport
How should you start a conversation with a patient?
With Open-Ended Questions or Statements
Ex: - How are you doing today?
- Is there anything I can get you?
In what types of situations should Open-Ended Questions or Statements be used?
- To begin interview
- To introduce a new section of questions
- Whenever the patient introduces a new topic
