Nursing impression

Question 1

What is a Nursing Impression?

Answer 1

Definition: A preliminary interpretation of a patient’s health based on collected data.
Purpose: Guides care planning, interventions, and communication.
* Share findings and impressions in simple terms.
* Highlight strengths, challenges, and provide education.

Question 2

Post-Interview

Answer 2

Document findings for effective communication.
* Reflect on the interaction for continuous improvement.

Question 3

Explaining Questions to Patients

Answer 3

1. Biographical Data : “I’m asking for basic details like your name, age, and pronouns to address you properly and understand your background.”
2. Reason for Seeking Care : “I’d like to understand why you’re here today to focus on your main concerns.”
3. OPQRSTIUA (Symptom Analysis) : “These questions help me learn about your symptoms, when they started, and how they affect your daily life.”
4. Family History : “This helps identify health conditions that might run in your family and affect you.”
5. Past Medical History : “Knowing about past illnesses, surgeries, or hospitalizations gives me a complete picture of your health.”
6. Medications : “It’s important to know what medications you take to avoid interactions or gaps in treatment.”
7. Social History : “I’ll ask about your lifestyle, work, and relationships since these can impact your health.”
8. Functional Assessment : “This helps me understand how you handle daily activities and if you need support.”
9. Sexual Health : “I’ll ask about your sexual health as it’s an important part of overall well-being and prevention.”
10. Review of Systems : “I’ll ask about your body systems to ensure we don’t miss anything related to your health.”

Question 4

Steps to Develop a Nursing Impression

Answer 4

Step 1: Gather Assessment Data
* Health History/Interview
* Observation Skills: Note non-verbal cues, behaviors, and validate observations with the patient.
* Psychological Assessment: Assess mood, cognition, and coping mechanisms as needed.
* SDoH
* Review of Systems (ROS): Assess systems “above” and “below” the primary complaint.
Step 2: Gather Physical Assessment Data
* Perform inspection, palpation, percussion, and auscultation tailored to the patient’s complaint.
* Compare findings to normal expectations and look for unexpected patterns.
* Focus on interconnected systems based on findings.
Step 3: Analyze Assessment Data
* Identify patterns across data (e.g., symptoms, history, physical findings).
* Use critical thinking to explore cause-and-effect relationships.
* Cluster related information to form a cohesive understanding of the patient’s health.
* Synthesize findings into a unified interpretation considering context (e.g., history, lifestyle, SDoH).
Step 4: Formulate Nursing Impression
* Combine findings to identify a suspected health issue with supporting evidence (e.g., symptoms, exam results).
* Avoid medical diagnoses; use terms like “possible [condition].”
* Example: “Possible pneumonia as evidenced by dyspnea, fever, and sputum, related to aspiration.”
Step 5: Care Planning and Interventions
* Create an evidence-based care plan with prioritized interventions.
* Involve the patient
* Take a holistic approach (both physical and psychosocial needs)
Step 6: Documentation
* Document findings, nursing impression, interventions, and the care plan clearly.
Step 7: Follow-Up
* Monitor outcomes: Regular assessments to evaluate intervention effectiveness.
* Adapt care: Adjust interventions if results differ from expectations.
* Engage the patient: Collect feedback and reassess the nursing impression based on new information.
* Evaluate results: Determine if the patient’s condition has improved or requires further adjustments.