Evidence-based Assessment, Cultural Competence, The Interview, The Complete Health History

Question 1

AA(D)PIE

A

Answer 1

A=Assessment

Recognize Clues

(Collect Data, Health Hx, Physical, Etc.)

Question 2

AA(D)PIE

A(D)

Answer 2

A(D)=Analyze (Diagnosis)

Analyze Clues

(Interpret data, validate diagnosis, compare clincial findings with abnormal and normal, make hypothesis)

Question 3

AA(D)PIE

P

Answer 3

P=Plan

Prioritize Hypothese & Generate solutions
Establish Priorities & Document Plan of Care

(Develop outcomes, identify interventions)

Question 4

AA(D)PIE

I

Answer 4

I=Implemmentation

What we do most of the time
Implement goals and interventions

Use Evidence-Based Interventions

(Provide health teaching and health promotion, document and modify, community resources)

Question 5

AA(D)PIE

E

Answer 5

E=Evaluate

What worked? What didn’t?
Use On-Going Assessment to Revise Diagnosis

(Include patient and significant others, progress towards outcomes)

Question 6

Subjective Data

Answer 6

What the client tells you

*Interview (Health Hx)

Question 7

Objective Data

Answer 7

Stuff I found

• Review of clinical data, physical exam
• what you (the nurse) see, hear, feel, and smell.

Question 8

Priority problem:

1st Level Critical thinking

Answer 8

Life threatening (ABCs)

Airway, breathing, circulation, large amounts of blood

Question 9

Priority problem:

2nd level Critical thinking

Answer 9

physiological (bodily)

Ex. long-term constipation, haven’t peed in 24 hours, change in mental status, acute pain

Question 10

Priority problem:

3rd level Critical thinking

Answer 10

discharage and education

Question 11

4 Types of Data

*Complete Database

Answer 11

Current/past health state

Baseline for future

Ex: primary care setting or upon admission to hospital

Question 12

4 Types of Data

*Focused Database

Answer 12

Focused or Problem-Centered (Episodic): Database is for limited or short-term problems

collect “mini” data base that concerns mainly one problem, cue or body system

Example: urgent care

Question 13

4 Types of Data

*Follow-Up Database

Answer 13

Follow-Up Database:
determine status of any identified acute and chronic problems

Regular and appropriate intervals

Note changes that have occurred

Evaluate whether the problem is getting better, worse, or if it is resolved

Identify coping strategies being used by the patient

Question 14

4 Types of Data

*Emergency Database

Answer 14

Emergency Database:

Rapid collection of crucial (life-saving) information

Interviewing the patient while simultaneously assessing airway, breathing, circulation, and level of consciousness

Complete database can follow once the patient is stabilized

Ex. ER

Question 15

Practice Question:
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?

Answer 15

Evaluate

Reassess the patient’s pain.

Question 16

Interviewing

Answer 16

Opening: “Hi, I’m so in so…”
Body: Gathering data using open-ended questions
Closing: “Thank you for your time.”

Question 17

facillitation

Answer 17

“Uh-huh, please go on”

Question 18

CC: Chief Complaint

Answer 18

Brief statement in person’s own words describing reason for visit;

enclosed in quotation marks to indicate person’s exact words

“Rash on my lower back“ or “Chest pain for 2 hours”

Ask: What brings you in today? even if chief complaint is already documented

Question 19

HPI: History of Present Illness Mnemonic

Answer 19

O, P, Q, R, S, T, U
O=Onset
P=Provoking
Q=Quality
R=Region
S=Severity
T=Time
U=Understanding

Question 20

Functional Assessment

Answer 20

Measures a person’s self-care abilities:
ADLs=bathing, eating, walking, dressing, cooking
*ask about alcohol use because it may interact with meds

Question 21

Pack years

Answer 21

of PPD x years smoked

Question 22

Health History

*DC: Children

Answer 22

Focus:

Age & Development

PMH: prenatal care, labor/delivery, postnatal, immunizations

Question 23

Health History

*DC: adolescents

Answer 23

Use HEEADSSS psychosocial assessment

Interview youth alone while the parent waits outside

Question 24

Health History

*DC: older adults

Answer 24

Older adults may shrug off symptoms as part of aging or present with acute problem while dealing with multiple chronic problems

Medications:

Person may not know drug name or purpose

May take large number of drugs prescribed by different physicians

**Ask person to bring in all medications to update your list

If unable to afford drug, may decrease dosage or not refill immediately

Travel to pharmacy may present a problem

Some share medications with neighbors or friends

*Address ways in which ADLs are affected by normal aging processes or by effects of chronic illness or disability

Question 25

Nursing Process

Answer 25

ADPIE-Assess, Diagnose/Analyze, Plan, Implement, Evaluate