Lesson 1 Beginning the Assessment

Question 1

The Nursing Process

Answer 1

(ADPIE)

Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation

Question 2

A systematic, rational method of planning and providing individualized nursing care.

Answer 2

The Nursing Process

Question 3

Characteristic of nursing process

Answer 3

It is cyclic and dynamic.
It is client centered.
It is planned.
It is goal directed.
It is universally applicable.

Question 4

Purpose of Nursing Process

Answer 4

1. Identify a client health status and actual or potential health care problems and needs.
   
   2. Establish plans to meet the identifying needs.
   3. Deliver specific nursing intervention to meet needs.

Question 5

Is a systematic and continuous collection, organization, validation and documentation of data.

Answer 5

Assessing

Question 6

Assessment process

Answer 6

I- Collecting data.
II- Organizing data.
III- Validating data.
IV- Documenting data.

Or

(COVID)

Question 7

Is the process of gathering information about clients, and health status.

Answer 7

Collecting data

Question 8

Types of data

Answer 8

1) Subjective data (Symptoms)
2) Objective data (Signs)

Question 9

these data that can be described or verified only by that person.

Answer 9

Subjective data

Question 10

e.g itching, pain, feelings, stress.

Answer 10

Subjective data (symptoms)

Question 11

obtained through observation and are verifiable.

Answer 11

Objective data

Question 12

e.g discoloration, lungs sounds, vomited 100ml.

Answer 12

Objective data (signs)

Question 13

these data that can be described or verified only by that person.

Answer 13

Sources of data

Question 14

Sources of data

Answer 14

a- client.
b- Health care
professionals.
c- Support people
d- Client records.

Question 15

How to create a proper environment

Answer 15

1. Settling in
2. Watch what you say
3. Communicate effectively

Question 16

How do I:

Settle In?

Answer 16

• choose a quiet, private, well-lit interview setting

-make sure that the patient is comfortable

-introduce yourself and explain the purpose of the health history and assessment

-reassure the patient that everything he says will be kept confidential

-tell the patient how long the interview

Question 17

How do I:

Watch what I say?

Answer 17

-assess the patient to see if language barriers exist

-speak slowly and clearly

-address the patient by a formal name

Question 18

How do I:

communicate effectively?

Answer 18

Realize that you and the patient communicate nonverbally as well as verbally.

Being aware of the two forms of communication that will aid you in the interview process.

Question 19

Types of communication strategies

Answer 19

1) Verbal communication strategy

2) Nonverbal communication strategy

Question 20

Nonverbal communication strategies

Answer 20

Listen attentively and make eye contact frequently

Use reassuring gestures (

nodding)

Watch for nonverbal cues that indicate the patient is uncomfortable

Be aware of your nonverbal behaviors

Observe the patient closely to see if he understands each question

Question 21

Verbal communication strategies

Answer 21

1) Silence
2) Facilitation
3) Confirmation
4) Reflection
5) Summary

Silence- besides encouraging the patient to continue talking, silence also gives you a chance to assess his ability to organize thoughts.

Facilitation- using such phrases as “please continue”, “go on”, and even “uh-huh” encourages the patient to continue with his story.

Confirmation- it helps ensure that you and the patient are on the same track. For example, you might say, “If I understand you correctly, you said..”

Reflection- it is repeating something that the patient has just said to help you obtain more specific information.

Clarification- when information is vague and confusing, use this technique. For example, if your patient says, “I can’t stand this”, you might respond, “what can’t you stand?”

Summary- this technique ensures that the data you’ve collected are accurate and complete. It signals that the interview is about to end.
Conclusion- this gives the patient the opportunity to gather his thoughts and make any pertinent final statements. You can do this by saying, “I think I have all the information I need now. Is there anything you would like to add?”

Question 22

Health history information

Answer 22

Biographic data
Chief complaint
Medical history
Family history
Psychosocial history
Activities of daily living

Question 23

Factors for assessment

Answer 23

(PQRST)

1) Palliative factors and Provocative factors
2) Quality
3) Radiation
4) Severity
5) Temporal factors

Question 24

is a clinical judgment about individual, family or community responses to actual and potential health problems/life processes.

Answer 24

Nursing diagnosis

Question 25

Types of Nursing diagnosis

Answer 25

1) Actual Nursing Diagnosis 2) Risk Nursing Diagnosis

Question 26

is a client problem that is present at the time of nursing assessment, and is based on the presence of associated signs and symptoms. e.g. impaired mobility.

Answer 26

Actual Nursing Diagnosis

Question 27

is a clinical judgment that a problem does not exit, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervention. e.g risk for infection

Answer 27

Risk Nursing Diagnosis

Question 28

Components of NANDA Nursing diagnosis

Answer 28

1- Problem: ( diagnostic label ) 2-Etiology :( related factor and risk factor): 3- Defining characteristics: Or (PED)

Question 29

There are words that have been added to some NANDA label to give additional meaning.

Answer 29

Problem: ( diagnostic label )

Question 30

identifies one or more probable causes of the health problem

Answer 30

Etiology :( related factor and risk factor):

Question 31

Are cluster of sign and symptoms that indicate the presence of a particular diagnostic label.

Answer 31

Defining characteristics:

Question 32

Nursing Diagnosis process:

Answer 32

1- Analyzing data. 2- Identifying health problem, risks and strengths. 3- Formulating diagnostic statement.

Question 33

is a deliberative, systematic phase of nursing process that involve decision making and problem solving .

Answer 33

Planning

Question 34

Types of planning

Answer 34

1) Initial Planning 2) Ongoing Planning 3) Discharge Planning

Question 35

the nurse who performs the admission assessment usually develops the initial comprehensive plan of care.

Answer 35

Initial Planning

Question 36

Is done by all nurses who work with the client. - It is the beginning of shift as the nurse plans the care to be given that day.

Answer 36

Ongoing Planning

Question 37

The process of anticipating and planning for needs after discharge

Answer 37

Discharge planning:

Question 38

Planning Process

Answer 38

1- Setting priorities. 2- Establishing client goals/desired out comes. 3- Selecting nursing strategies. 4- Writing nursing orders.

Question 39

The specific strategies chosen should focus on eliminating or reducing the etiology.

Answer 39

Implementing

Question 40

Selecting nursing intervention and activities are actions that nurse performs to a achieve client goals.

Answer 40

Implementing

Question 41

Types of Nursing Intervention

Answer 41

1) Independent intervention 2) Dependent intervention 3) Collaborative intervention

Question 42

are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.

Answer 42

Independent intervention

Question 43

are activities carried out under the physician orders.

Answer 43

Dependent intervention

Question 44

are actions the nurse carries out in collaboration with other health team member.

Answer 44

Collaborative intervention

Question 45

Is the phase in which the nurse puts the nursing care plan into action.

Answer 45

Implementing

Question 46

Process of implementing:

Answer 46

(RDIDC) 1- Reassessing the client. 2- Determining the nurse need for assistance. 3- Implementing the nursing orders (strategies). 4- Delegating and Supervising. 5- Communicating the nursing actions.

Question 47

Is to judge or to appraise.

Answer 47

Evaluation

Question 48

is a planned, ongoing, purposeful activity in which clients and health care professionals determine the clients progress toward goals

Answer 48

Evaluation

Question 49

The effectiveness of the Nursing Plan

Answer 49

Evaluating

Question 50

Process of evaluating client responses

Answer 50

1- Identify the desired out comes. 2- Collecting data related to desired out comes. 3- Compare the data with desired out comes 4- Relate nursing actions to client goals/desired outcomes. 5- Draw conclusions about problem status. 6- Continue to modify or terminate the clients care plan.