Lecture 1 - Communication, Health History, and the Nursing Process Flashcards
What is the Nursing Process?
Involves 5 dynamic steps:
- Assessment
- Diagnosis
- Planning
- Implementation/
Intervention - Evaluation
Important: the nursing process is not linear
What is the purpose of Assessment?
Inform clinical judgement about the patient’s state of health, and to identify factors impacting it.
What two things must an effective assessment Include?
- A systematic approach to data collection
- Critical judgement
What is Diagnostic Reasoning?
An analysis of health data that recognizes problems and targets priority needs.
“Develop a sense of intuition” - Prof
What are the four components of Diagnostic Reasoning
- Dealing with signs and symptoms
- Formulate hypothesis
- Collect data on each of these assumptions
- Evaluate each hypothesis with this new data
What are the three levels of priority setting?
1st - immediately life threatening
2nd - Require prompt intervention to prevent deterioration
3rd - Important, but no imminent threat or short-term harm
What are some examples of first-priority issues?
Unestablished airway, cardiac issues, hemorrhage
What are some examples of second priority issues?
- Mental status change
- Kidney injury
- Stroke
- Acute pain
- Migraine
- Risk of infection
What are some examples of third priority issues?
- Broken bone
- Mobility issues
- Mild illness
- Excessive drinking
- Smoking
What are some examples of collaborative problems?
Diabetes, cancer, autoimmune disease, unemployment
Describe the Rational (or Reflective)
Approach to communication
Approach all interactions as an inquirer, using reflexivity to govern your conduct an assessment while considering intrapersonal, interpersonal, and contextual factors.
What is Unconditional Positive Regard?
Keeping an optimistic view of the patient and their strengths. Show empathy for their emotional responses and lived experiences
What are some ways to maintain a comforting physical environment for the patient to ensure effective communication?
–> Keep a distance of 1.5 m and sit 90 degrees from them. Remain at eye level
–> Minimize interruptions
–> Do not sit patients with their back to the door
–> Be honest about note taking and keep it minimal
What is the purpose of open-ended questions in the interview?
Allows patient to share personal experience (subjective data). Often used at the beginning of the interview.
What is the purpose of closed ended questions during the interview?
Used to fill in specific gaps in narrative or for clarification. Helpful in closing interview.
What are the five types of verbal responses a nurse can use to encourage the patient to lead discussion?
- Facilitation
- Silence
- Reflection
- Empathy
- Clarification
What are the three types of verbal communication a nurse can use while leading conversation?
- Interpretation
- Explanation
- Summary
What does Dx stand for?
Diagnosis
What is the definition of Hx
Health History: collection of subjective and objective data.
Can be focused or whole.
What is the purpose of taking Hx?
To identify health issues and strengths and guide the physical exam. Is the basis for more of nursing/medical care
What information does the Hx include?
- Bio
- Reason for seeking care
- Current health/illness history
- PMHx
- FamHx
- RoS
- ADLs and IADLs
What kind of Information is reviewed in the Bio?
Name, Birth Date and Age, Sex and Gender, Birthplace, Address and phone number.
Always record source of information: Patient, POA, etc.
What information is covered in Reason for Seeking Care?
Direct quote from patient as well as symptoms (subjective) and signs (objective)
How is information about current health and illness collected?
PQRSTU collects data about characteristics of symptoms.
P: Provocative or Palliative?
Q: Quality and Quantity
R: Region or Radiation
S: Severity
T: Timing
U: Understanding of patient
What information is collected in the PMHx?
–> Allergies
–> Medication use
–> Previous/ongoing illness, injury, procedures, hospitalizations
–> Date of last examination
–> Vaccination status
–> OBS/GYN history
What acronym is used to quantify a female’s past OBS history?
GTPAL; all answers are numbers
G: Gravidity
T: Term deliveries
P: Preterm deliveries
A: Abortions
L: Living children
What kind of information is collected in the FamHx?
Age, health, and cause of death of immediate blood relatives.
What is the purpose of RoS?
Review of Systems is used to evaluate the past/present state of each system, double-check information collected earlier, and evaluate health promotion practices.
When performing an RoS, what language should be used?
Positive statements such as presence of absence. Avoid negative terms such as denies, refuses, not adheres, or not compliant.
What kind of Information is collected in a Functional Assessment?
–> Occupation
–> Education
–> Family & relationships
–> Exercise & nutrition
–> Sleep/rest
–>Personal habits
–> Substance use
–> ADLs/IADLs
When is the acronym SOAP used? What does it stand for?
Used in charting:
Subjective information
Objective observation
Assessment
Plan
When is the acronym SBAR used? What does it stand for?
Used in verbal communication with colleagues:
Situation
Background
Assessment
Recommendation (both ways)
Which four things govern evidence-informed clinical decision making?
–> Evidence and research
–> Physical examination and assessment of patient
–> Clinical Expertise
–> Patient preferences and values
What is episodic/problem-centered care?
Care + Assessment done with intentions of treating/managing a specific health concern, without intentions of continuing the relationship.
