the nursing process

Question 1

What is the abbreviation of the 5 steps in the nursing process?

Answer 1

ADPIE

Question 2

What does ADPIE stand for with regards to the 5 steps of the nursing process?

Answer 2

Assessment, Diagnosis, Planning, Implementation and Evaluation.

Question 3

What is a health assessment defined as?

Answer 3

The collection of subjective and objective data that enables assessment of clients overall level of functioning.

Question 4

State 3 examples of common frameworks used for health assessment.

Answer 4

1. The emergency cycle
2. The body systems framework
3. The head to toe framework

Question 5

what are the 4 basic types of assessment (based on their circumstances?

Answer 5

1. Initial, comprehensive assessment (when a patient first arrives).
2. Ongoing, or partial assessment (for an existing patient)
3. Focused, or problem-oriented assessment (when a patient presents with a specific issue)
4. Emergency assessment (emergency situation).

Question 6

What information is attained from a patient through an initial comprehensive assessment?

Answer 6

1. Current medical diagnosis
2. Past medical and surgical history
3. Relevant family medical history
4. Allergies and adverse reactions (if any)
5. current medications

Question 7

What information is obtained from an ongoing or partial assessment?

Answer 7

1. Identification of deterioration or improvement in the patient.
2. reassessment of normal body systems to detect any potential problems.

Question 8

What information is obtained in a focused or problem oriented assessment?

Answer 8

1. Information specifically about the nature of the health issue;
   - COLDSPAA abbreviation.

Question 9

COLDSPAA is used in a problem oriented assessment to acquire details about a medical condition.
What does COLDSPAA stand for?

Answer 9

Character, Onset, Location, Duration, Severity, Pattern, Associated factors, Affect on patient.

Question 10

What information is obtained in an emergency assessment?

Answer 10

1. Information about the status of the vital function of the body;
   - ABCD’s

Question 11

What does ABCD’s abbreviation mean, with regards to emergency assessment?

Answer 11

Airways, breathing, circulation, Defibrillation.

Question 12

What is the term used for the process in which the nurse obtains this assessment information?

Answer 12

Interviewing

Question 13

What are the three phases of the interview?

Answer 13

1. Introductory phase
2. working phase
3. summary, termination or closing phase.

Question 14

What is involved in the introductory phase of the interview?

Answer 14

a) Introduce yourself to the patient
b) explain the purpose of the interview and what questions will be asked
c) explain the purpose for note taking and reassure them of confidentiality.

Question 15

What is the purpose of conducting the introductory phase of the interview? Why not just ask the questions straight away?

Answer 15

Bedside manner and establishing rapport;

a rapport must be established with the patient, to gain their trust and comfort.

Question 16

How is the patient’s environment to be prepared for their assessment/interview?

Answer 16

the environment is to be:

comfortable (right temperature), private, quiet and fully equipped.

Question 17

How is the patient to be prepared for the assessment/interview?

Answer 17

their rights must be protected:

• leave the room as they undress
• respect cultural and religious beliefs
• respect the patient’s desire to keep someone with them during the interview or assessment.
• approach them from the right hand side

Question 18

What is involved in the working phase of the interview?

Answer 18

This is when the assessment/interview questions can be asked, in order to obtain the subjective and objective data.

Question 19

What is subjective data?

Answer 19

Complaints which the patient tells the nurse.

Remember, what the patient ‘says’ to you.

Question 20

What is objective or biological data?

Answer 20

Official personal information and contact details about the patient.