chapter 16 Flashcards
Mention the types of assessment.
Patient centered interview (nursing history)
Periodic assessment (ongoing contact w/ patients
Physical examination (patients present symptoms)
Types of data
subjective and objectives
A physical examination is a comprehensive review of all major body system, providing what type of data about a patient’s clinical status???
objective data
When you begin a formal patient centered interview for the purpose of collecting a nursing history you will go through the traditional 3 interview phases.
1-orientation or setting an agenda
2-working (collecting assessment data)
3-termination of the interview
Tonya is doing a follow-up interview to learn more about Mr.
Lawson’s home situation. She explains, “Mr. Lawson, it looks as if
your doctor wants to send you home tomorrow. It’s important for
us to know more about how you care for yourself at home. Are you
comfortable, and can I take a few minutes to talk about your dis-
charge now?” Mr. Lawson replies, “I feel a bit better, and, yes, I’ve
been thinking about some questions I want to ask.” Tonya replies,
“Good. We’ll start there.”
What phase of the interview is this example???
orientation/setting agenda
begin by
having patients explain their symptoms or physical or psychological
concerns. Ask them to describe what they know about their health
problems or to describe their health care expectations. Use attentive lis-
tening and summarize key issues to validate your understanding with
the patient, and encourage him or her to tell a full story
This an example of what interview phase??
working/ collecting data
A patient is admitted to the hospital with shortness of breath. As the
nurse assesses this patient, the nurse is using the process of:
1-evaluation.
2-data collection.
3-problem identification.
4-testing a hypothesis.
2
“So, tell me more about ….” or “What are your concerns about
this?” or “Tell me how you have been feeling.?” This approach does not
presuppose a specific answer. You are exploring with the patient.
What type of ended question is???
opened ended question
This technique requires short answers and clarifies previous information
to provide a more comprehensive database.
Example: the nurse asks, “How
often does the diarrhea occur?” and “Do you have pain or cramping?’
closed ended question s
Reinforce your interest in what a patient has to say through the use of good eye contact and listening.
Example: “all right,”
“go on,” or “uh-huh.”
back channeling
The assessment process
data collection
Interpretation
Validation
During the interpretation assessment process ——-is used to obtain information through the use of common sense
cue
The nurse asks a patient the following series of questions:
“Describe for me how much you exercise each day.” “How do you
tolerate the exercise?” “Is the amount of exercise you get each
day the same, less, or more than what you did a year ago?” This
series of questions would likely occur during which phase of a
patient-centered interview?
1. Orientation
2. Working phase
3. Data interpretation
4. Termination
2
A nurse observes a patient walking down the hall with a shuf-
fling gait. When the patient returns to bed, the nurse checks the
strength in both of the patient’s legs. The nurse applies the infor-
mation gained to suspect that the patient has a mobility problem.
This conclusion is an example of:
1. Reflection.
2. Clinical inference.
3. Cue.
4. Validation.
2
- Place the following steps of the assessment process in the correct
order. - Compare data with another source to determine data accuracy.
- As a pattern forms, probe and frame further questions.
- Interview a patient, observe behavior, and gather physical
assessment findings. - Cluster cues that relate together, make inferences, and identify
emerging patterns. - Differentiate important data from the total data you collect.
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