Jen ch 16

Question 1

assessment

Answer 1

deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns

two steps:

1 Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record)

2 The interpretation and validation of data to ensure a complete database

Question 2

cue

Answer 2

Information that a nurse acquires through hearing, visual observations, touch, and smell

Question 3

Gordon’s functional health patterns

Answer 3

Health perception–health management pattern: Describes patient’s self-report of health and well-being; how patient manages health (e.g., frequency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices

Nutritional-metabolic pattern: Describes patient’s daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain

Elimination pattern: Describes patterns of excretory function (bowel, bladder, and skin)

Activity-exercise pattern: Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

Sleep-rest pattern: Describes patterns of sleep, rest, and relaxation

Cognitive-perceptual pattern: Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

Self-perception–self-concept pattern: Describes patient’s self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image)

Role-relationship pattern: Describes patient’s patterns of role engagements and relationships

Sexuality-reproductive pattern: Describes patient’s patterns of satisfaction and dissatisfaction with sexuality pattern; patient’s reproductive patterns; premenopausal and postmenopausal problems

Coping–stress tolerance pattern: Describes patient’s ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

Value-belief pattern: Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient’s choices or decisions .

Question 4

subjective data

Answer 4

Information gathered from patient statements; the patient’s feelings and perceptions. Not verifiable by another except by inference.

Question 5

objective data

Answer 5

Information that can be observed by others; free of feelings, perceptions, prejudices.

Question 6

sources of data

Answer 6

• patient
• family and significant others
• health care team
• medical records
• other records and scientific literature
• nurse’s experience

Question 7

Patient-Centered Interview

Answer 7

• set the stage
• set an agenda (gather info about patient’s chief concerns or problems then set agenda
• collect assessment/nursing health history
• terminate the interview

Question 8

open ended questions

Answer 8

Form of question that prompts a respondent to answer in more than one or two words. (Potter 1306)
Potter, Patricia, Anne Perry, Patricia Stockert, Amy Hall . Fundamentals of Nursing, 8th Edition. Mosby, 2013. <978-0-323-07933-4>.978-0-323-07933-4>

Question 9

back channeling

Answer 9

ncludes active listening prompts such as “all right,” “go on,” or “uh-huh.” These indicate that you have heard what the patient says and are interested in hearing the full story. Back channeling encourages a patient to give more details.

Question 10

probing

Answer 10

encourage a full description without trying to control the direction the story takes. This requires you to probe with further open-ended statements such as, “Is there anything else you can tell me?” or “What else is bothering you?”

Question 11

closed-ended questions

Answer 11

Form of question that limits a respondent’s answer to one or two words.

Question 12

nursing health history

Answer 12

Data collected about a patient’s present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

Question 13

validation

Answer 13

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.

Question 14

two approaches to gathering a comprehensive assessment

Answer 14

use of a structured database format and use of a problem-focused approach.