NR 226 Final Exam Study Outline Latest
The Nursing Process
o The purpose of the nursing process is to diagnose and treat human
responses (e.g., patient symptoms, need for knowledge) to actual
orpotential health problems. Use of the process allows nurses to
helppatients meet agreed-on outcomes ...
NR 226 Final Assessment- Chamberlain College of Nursing
NR 226 Final Exam Study Outline Latest
The Nursing Process
o The purpose of the nursing process is to diagnose and treat human
responses (e.g., patient symptoms, need for knowledge) to actual
orpotential health problems. Use of the process allows nurses to
helppatients meet agreed-on outcomes for better health.
o The nursing process requires a nurse to use the general and specific
critical thinking competencies described earlier to focus on a
particular patient's unique needs. The format for the nursing
processis unique to the discipline of nursing and provides a
common language and process for nurses to “think through”
patients' clinicalproblems
• 5 Steps of the Nursing Process (ADPIE)
o Assessment
▪ Phases of interview/assessment
• An interview is an approach for gathering subjective and
objective data from a patient through an organized
conversation. An initial interview involves collecting a
nursing health history and gathering
information about a patient's condition
• 1. Orientation and Setting an Agenda
o Begin an interview by introducing yourself and
your position and explaining the purpose of the
interview. Explain why you are collecting data and
assure patients the tall of the information will be
confidential.
o Your aim is to set an agenda for how you will
gather information about a patient's current chief
concerns or problems. Remember, the best clinical
interview focuses on a patient's goals,
preferences, and concerns and not on your agenda.
• 2. Working Phase-Collecting Assessment or Nursing Health
History
NR 226 Final Assessment- Chamberlain College of Nursing
,NR 226 Final Assessment- Chamberlain College of Nursing
o Start an assessment or a nursing health history
NR 226 Final Assessment- Chamberlain College of Nursing
,NR 226 Final Assessment- Chamberlain College of Nursing
with open- ended questions that allow patients to
describe more clearly their concerns and problems.
For example, begin by having a patient explain
symptoms or physical concerns and describe what
he or she knows about the health problem or ask
him or her to describe health care expectations.
NR 226 Final Assessment- Chamberlain College of Nursing
, NR 226 Final Assessment- Chamberlain College of Nursing
o Use attentive listening and other therapeutic
communication techniques that encourage a
patient to tell his or her story.
• 3. Terminating an Interview
o Termination of an interview requires skill. You
summarize your discussion with a patient and
check for accuracy of the information collected.
Give your patient a clue that the interview is
coming to an end. For example, say, “I have just
two more questions. We'll be finished in a few
more minutes.”
o This helps a patient maintain direct attention
without being distracted by wondering when
the interview will end.
▪ Methods of obtaining data
• An assessment is necessary for you to gather
information to make accurate judgments about a
patient's current condition. Your information comes
from:
• The patient through interview, observations, and physical
examination.
• Family members or significant others' reports and
response to interviews.
• Other members of the health care team.
• Medical record information (e.g., patient history,
laboratory work, x-ray film results,
multidisciplinaryconsultations).
• Scientific and medical literature (evidence
about disease conditions, assessment
techniques, and standards).
▪ Subjective Data
• Subjective data are your patients' verbal descriptions of
their health problems. For example, Mr. Lawson's self-
report of pain at the area
where his incision slightly separated is an example of
subjective data. Subjective data include patients'
feelings, perceptions, and self-report of symptoms.
• Only patients provide subjective data relevant to their health
NR 226 Final Assessment- Chamberlain College of Nursing
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