Methods Of Colllecting Data, Health History

Question 1

is a process of sharing information and meaning, of sending and receiving messages. The messages we communicate are both verbal and nonverbal

Answer 1

Communication

Question 2

The ___ being sent is more accurate than the verbal one. Be conscious on your beliefs and values and do not let them influence your verbal or nonverbal communication

Answer 2

nonverbal message

Question 3

includes vocal cues or paralinguistics, action cues or kinetics, object cues, personal space, and touch.

Answer 3

Nonverbal behavior

Question 4

Methods of Collecting Data

Answer 4

Interview
Observation
Physical Assessment

Question 5

Structured communication intended to obtain
subjective data

It is a planned purposeful conversation

Answer 5

Interview

Question 6

INTERVIEW

Interpersonal skills are very important, this is
called the

Answer 6

therapeutic use of self

Question 7

2 types of approaches of interview

Answer 7

Directive interview
Non-directive interview

Question 8

are structured with specific questions and are controlled by the nurse. These interviews require less time and are very effective for obtaining factual data.

Answer 8

Directive interview

Question 9

are controlled by the patient, although the nurse often needs to summarize and clarify the data.

These interviews require more time than directive interviews but are very effective at eliciting the patient’s perceptions and feelings

Answer 9

Non-directive interview

Question 10

Types of interview questions

Answer 10

Closed-ended
Open-ended

Question 11

Actions that convey attentive listening (LOVERS)

Answer 11

Lean forward
Open
Voice quality
Eye contact
Relax
Sit squarely

Question 12

Phase of interview

Answer 12

Introductory phase
Working phase
Termination phase

Question 13

is the time to introduce yourself to your patient, put him or her at ease, and explain the purpose of the interview and the time frame needed to complete it

Answer 13

Introductory phase

Question 14

is often where data collection occurs. It is usually very structured; it is also the longest phase.

Answer 14

Working phase

Question 15

is the end of the interview process. you need to summarize and restate your findings. This provides an opportunity to clarify the data and share your findings with the patient.

Answer 15

Termination phases

Question 16

• Leading the patient
• Biasing yourself
• Letting family members answer for patient
• Asking more than one question at a time
• Not allowing enough response time
• Using medical jargon
• Assuming rather than clarifying and verifying
• Taking patient’s response personally
• Feeling personally uncomfortable
• Using clichés
• Offering false reassurance
• Asking persistent or probing questions
• Changing the subject
• Taking things literally
• Giving advice
• Jumping to conclusions

Answer 16

Common interview pitfalls

Question 17

Entails deliberate use of your senses of sight,
smell, and hearing to collect data.

Look at both your patient and his or her environment to detect anything out of the ordinary.

Answer 17

Observation

Question 18

Systematic selection, watching, or noticing and
recording patient’s characteristic, behaviors, and
events

Answer 18

Observation

Question 19

provides the objective data base. It helps you
assess your patient’s health status and identify
actual or potential problems.

Answer 19

Physical Assessment

Question 20

is a process which results to diagnostic statement or nursing diagnosis

Its purpose is to identify the patient’s health care
need and prepare diagnostic statement/s

It involves identifying and prioritizing actual or
potential health problems

Answer 20

Diagnosing

Question 21

A statement of a patient’s potential or actual health problems which nurses, by virtue of their
education and experience are capable and
licensed to treat (Gordon, 1976)

Answer 21

Nursing Diagnosis

Question 22

It is a clinical judgment about an individual,
family, or community in response to actual and
potential health problems and life process (NANDA)

Answer 22

Nursing Diagnosis

Question 23

describes a disease or pathology of specific organs or body system which can be treated thru medical intervention

Answer 23

Medical Diagnosis

Question 24

Describe an actual, risk, or human response to health problem that nurses are responsible for treating independently

Answer 24

Nursing Diagnosis

Question 25

What are types of nursing diagnosis

Answer 25

Types: 1. Actual nursing diagnosis 2. Potential/risk nursing diagnosis 3. Possible nursing diagnosis 4. Syndrome nursing diagnosis 5. Wellness nursing diagnosis

Question 26

Describes human responses to levels of wellness in an individual , family or community that have a readiness for enhancement

Answer 26

Wellness Nursing Diagnosis

Question 27

Parts of a complete nursing diagnosis

Answer 27

Problem Etiology Signs and symptoms

Question 28

Formula in stating health problem for Actual nursing diagnosis

Answer 28

P + E + S

Question 29

Formula in stating health problem for risk nursing diagnosis

Answer 29

P + risk factors

Question 30

Formula in stating health problem for possible nursing diagnosis

Answer 30

Data but inadequate and with need for further ingvestigation

Question 31

Formula in stating health problem for wellness diagnosis

Answer 31

Healthy response, high level of wellness

Question 32

Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care

Answer 32

Planning

Question 33

It is a mental formulation of a proposed method of doing or making something in achieving a given end

Answer 33

Planning

Question 34

Its purpose is to identify patient’s goals and appropriate nursing interventions In ____, nurses should set priorities in collaboration with patient Goals could be long-term or short-term Objective should be SMART

Answer 34

Planning

Question 35

are activities that the nurse plans and must be implemented to help a patient achieve the goals

Answer 35

Nursing intervention

Question 36

Nurses should select ____ that are safe, specific, realistic and feasible Nurses should understand the reason for any _____, the expected effect, and any potential problems that may result (rationale)

Answer 36

Intervention

Question 37

Types of nursing intervention

Answer 37

Development Supplemental Facilitative

Question 38

Types of nursing intervention Enhances patient’s capability for self-care

Answer 38

Developmental

Question 39

Types of nursing intervention nurse doing things for the patient because he lacks technical knowledge or has physical disability

Answer 39

Supplemental

Question 40

Types of nursing intervention nurse removes barriers to care

Answer 40

Facilitative

Question 41

Types of nursing function

Answer 41

Facilitative Independent Dependent Collaborative

Question 42

It involves determining the effectiveness of your plan. • Did you meet your goals and outcomes? • Need for patient reassessment

Answer 42

Evaluation

Question 43

Every assessment that follows also needs to be documented. To ensure continuity of care, your patient’s assessment needs to be communicated to all members of the healthcare team involved in her or his care. ___ is one way of communicating patient assessment and intervention

Answer 43

Documentation

Question 44

Documentation Methods

Answer 44

1. Source-oriented or problem-oriented documentation a. SOAPIE b. PIE c. DAR (FDAR) 2. Charting by exemption (CBE) - is a shorthand documentation method frequently used to save time. 3. Narrative method

Question 45

Provides the subjective database for your assessment. The purpose of it is to identify not only actual or potential health problems but also your patient’s strengths. As well as identify supports, identify teaching needs, identify discharge needs, identify referral needs.

Answer 45

Health History

Question 46

Reason for seeking care

Answer 46

Chief complaint

Question 47

Types of health history

Answer 47

Complete health history Focused health history

Question 48

includes biographical data, reason for seeking care, current health status, past health status, family history, a detailed review of systems, and a psychosocial profile

Answer 48

Complete health history

Question 49

focuses on an acute problem, so all of your questions will relate to that problem.

Answer 49

Focused health history

Question 50

Provide you with direct information related to a current health problem, alert you to risk factors for health problems, and point out the need for referrals. ____ include the patient’s name, address, phone number, contact person, age/birth date, place of birth, gender, race, religion, marital status, educational level, occupation, and social security number/ health insurance.

Answer 50

Biographical data

Question 51

Level of preventive healthcare

Answer 51

Primary Secondary Tertiary

Question 52

• Usual state of health. • Any major health problems. • Usual patterns of healthcare. • Any health concerns.

Answer 52

Current health status

Question 53

assesses childhood illnesses, hospitalizations, surgeries, serious injuries, adult medical problems (including serious or chronic illnesses), immunizations, allergies, medications, recent travel, and military service. The purpose is to identify any health factors from the past that may have a direct relationship to your patient’s current health status.

Answer 53

Past health history

Question 54

Provides clues to genetically linked or familial diseases that may be risk factors for your patient.

Answer 54

Family history

Question 55

Is a litany of questions specific to each body system. The questions are usually about the most frequently occurring symptoms related to a specific system

Answer 55

Review of systems

Question 56

Developmental assessments are often performed on ___ because the developmental changes that occur at this age are very observable and measurable.

Answer 56

children

Question 57

Illness and hospitalization can have a major impact on a child’s growth and development, by either halting its progression or regressing it to an earlier stage.

Answer 57

Developmental consideration

Question 58

Focuses on health promotion, protective patterns, and roles and relationships. It includes questions about healthcare practices and beliefs, a description of a typical day, a nutritional assessment, activity and exercise patterns, recreational activities, sleep/rest patterns, personal habits, occupational risks, environmental risks, family roles and relationships

Answer 58

Psychosocial profile

Question 59

Is a process during which you use your senses to collect objective data. Most patient view PE with at least some anxiety

Answer 59

Physical Examination

Question 60

• Goal is to identify variations from normal. • Explain procedure first • Head to Toe • Unaffected areas before affected

Answer 60

Physical Examination (PE)

Question 61

Skills required by the nurse

Answer 61

Communication skills Observation skills Assessment techniques

Question 62

Assessment techniques

Answer 62

Inspection Palpation Percussion Auscultation

Question 63

___ is the most frequently used assessment technique, but its value is often overlooked The visual examination (using naked eye) of the patient for detection of significant physical features

Answer 63

Inspection

Question 64

You are using your sense of touch to collect data. ____ is used to assess every system. It usually follows inspection, but both techniques are often performed simultaneously. ___ allows you to assess surface characteristics, such as texture, consistency, and temperature, and allows you to assess for masses, organs, pulsations, muscle rigidity, and chest excursion

Answer 64

Palpation

Question 65

Types of palpation

Answer 65

Light palpation Deep palpation

Question 66

May obtain data such as • presence of mass • Organ enlargement • Tenderness • Swelling • Moisture • Temperature • texture

Answer 66

PALPATION

Question 67

For fine tactile discriminations, such as texture of skin and size of lymph nodes, use ___ because they are most sensitive areas

Answer 67

fingers

Question 68

For temparature use ___ of the hands/fingers

Answer 68

dorsa

Question 69

____ aspect of the hands are more sensitive to vibration

Answer 69

Palmar

Question 70

For position and consistency, use

Answer 70

grasping action of the fingers

Question 71

Use ____ to determine tenderness

Answer 71

ballottement

Question 72

When palpating abdomen, particularly during deep palpation, use ___ technique

Answer 72

bimanual

Question 73

____ is used to assess density of underlying structures It entails striking a body surface with quick, light blows and eliciting vibrations and sounds. The sound determines the density of the underlying tissue and whether it is solid tissue or filled with air or fluid.

Answer 73

Percussion

Question 74

Types of percussion

Answer 74

Direct/immediate percussion Indirect or mediate Fist or blunt

Question 75

is directly tapping your hand or fingertip over a body surface to elicit a sound or to assess area of tenderness

Answer 75

Direct immediate percussion

Question 76

place your non- dominant hand over a body surface, pressing firmly with your middle finger

Answer 76

Indirect or mediate

Question 77

to assess tenderness of an organ

Answer 77

Fist or blunt percussion

Question 78

Mapping out location and size of an organ Determining density (air, fluid, solid) of a structure Detecting superficial mass (up to 5 cm deep) Eliciting pain if underlying structure is inflamed Eliciting a DTR using a percussion hammer

Answer 78

Uses for percussion

Question 79

What are percussion sounds

Answer 79

Resonance Tympany Dullness Hyperresonance Flatness

Question 80

Intensity: Moderate to loud Pitch: Low Duration: Long Quality: Hollow Source: Normal Lung

Answer 80

Resonance

Question 81

Intensity: Loud Pitch: High Duration: Moderate Quality: Drumlike Source: Gastric air bubble; intestinal air

Answer 81

Tympany

Question 82

Intensity: Soft to moderate Pitch: Medium Duration: Moderate Quality: Thudlike Source: Liver; full bladder; pregnant uterus

Answer 82

Dullness

Question 83

Intensity: Very loud Pitch: Very low Duration: Very long Quality: Booming Source: Hyper inflated lung (as in emphysema)

Answer 83

Hyperresonance

Question 84

Intensity: Soft Pitch: High Duration: Short Quality: Flat Source: Muscle

Answer 84

Flatness

Question 85

involves using your sense of hearing to collect data You will listen to sounds produced by the body, such as heart sounds, lung sounds, bowel sounds, and vascular sounds.

Answer 85

Auscultation

Question 86

Types of auscultation

Answer 86

Direct auscultation Indirect auscultation

Question 87

Usually last technique during PE (exception – abdomen, it’s the 2nd technique after inspection) ABDOMEN = IAPP Use stethoscope to block sounds not magnify • Diaphragm-firmly against skin • Bell- lightly against skin

Answer 87

Auscultation

Question 88

Frequency of sound vibrations, high or low.

Answer 88

Pitch

Question 89

loudness of sound: loud or soft (amplitude)

Answer 89

Intensity

Question 90

length of sound: short, long

Answer 90

Duration

Question 91

subjective terms- harsh, tinkling, etc

Answer 91

Quality

Question 92

• Study of the whole individual • Overall impression • Begins at the first encounter with a person • Introduction to the physical assessment • Composed of 4 parts: physical appearance, body structure, mobility & behavior

Answer 92

General survey

Question 93

Age Sex LOC Skin color Facial features

Answer 93

Physical appearance

Question 94

Stature Nutrition Symmetry Posture Position Body contour

Answer 94

Body structure

Question 95

Gait Range of motion

Answer 95

Mobility

Question 96

Behavior

Answer 96

Facial expression Mood Speech Dress/hygiene

Question 97

• S- Severity • L- Location • I- Influencing factors • D- Duration • A- Associated Symptoms

Answer 97

Assessing Distress/Pain