Podcast
Questions and Answers
What is the appropriate distance for conducting an interview in Arab countries?
What is the appropriate distance for conducting an interview in Arab countries?
Which of the following statements correctly describes the 'Closing' stage of an interview?
Which of the following statements correctly describes the 'Closing' stage of an interview?
Which of the following is NOT a recommended technique for closing an interview?
Which of the following is NOT a recommended technique for closing an interview?
What role does the nurse's greeting play in the 'Opening' stage of an interview?
What role does the nurse's greeting play in the 'Opening' stage of an interview?
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In organizing data obtained during an interview, which model is specifically mentioned as a non-nursing model?
In organizing data obtained during an interview, which model is specifically mentioned as a non-nursing model?
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Which component of the nursing health history provides insight into the patient's experience and perception of their symptoms?
Which component of the nursing health history provides insight into the patient's experience and perception of their symptoms?
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What is NOT included in the history of present illness when describing symptoms?
What is NOT included in the history of present illness when describing symptoms?
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Which of the following reflects a method of obtaining subjective data during a nursing health history assessment?
Which of the following reflects a method of obtaining subjective data during a nursing health history assessment?
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What type of data reflects observable findings that can be assessed by a nurse or observer?
What type of data reflects observable findings that can be assessed by a nurse or observer?
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In assessing a patient's lifestyle, which of the following is least relevant?
In assessing a patient's lifestyle, which of the following is least relevant?
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During which part of the nursing health history would a nurse inquire about previous hospitalizations?
During which part of the nursing health history would a nurse inquire about previous hospitalizations?
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Which of these aspects is crucial for understanding pain characteristics in the history of present illness?
Which of these aspects is crucial for understanding pain characteristics in the history of present illness?
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What is considered a palliative factor in the context of the history of present illness?
What is considered a palliative factor in the context of the history of present illness?
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Which statement accurately differentiates between subjective and objective data?
Which statement accurately differentiates between subjective and objective data?
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What is considered a primary source of data in a clinical setting?
What is considered a primary source of data in a clinical setting?
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In which type of interview does the nurse maintain control over the discussion?
In which type of interview does the nurse maintain control over the discussion?
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Which of the following is an example of an open question in an interview?
Which of the following is an example of an open question in an interview?
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Which factor should be considered to ensure effective planning of an interview with a hospitalized client?
Which factor should be considered to ensure effective planning of an interview with a hospitalized client?
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What is a characteristic of close questions used in a directive interview?
What is a characteristic of close questions used in a directive interview?
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Which observation method involves using senses to gather data?
Which observation method involves using senses to gather data?
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What can be categorized as an objective piece of data?
What can be categorized as an objective piece of data?
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What is the primary purpose of the nursing process?
What is the primary purpose of the nursing process?
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Which statement best describes the nature of the nursing process?
Which statement best describes the nature of the nursing process?
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What is the focus of problem-focused assessment?
What is the focus of problem-focused assessment?
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When is an emergency assessment performed?
When is an emergency assessment performed?
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What defines a time-lapsed reassessment?
What defines a time-lapsed reassessment?
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Which type of assessment is typically performed within a specified time after admission?
Which type of assessment is typically performed within a specified time after admission?
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What is essential for all phases of the nursing process?
What is essential for all phases of the nursing process?
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How is assessment described in the context of the nursing process?
How is assessment described in the context of the nursing process?
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Study Notes
Fundamentals of Nursing - 2nd Lecture
- This is a lecture on the nursing process.
- The nursing process is a systematic, rational way to plan and provide care.
- A process is a set of steps or actions that lead to achieving a goal.
- The nursing process identifies a client's health status, potential problems, establishes plans to meet needs, and delivers interventions.
Steps of the Nursing Process
- Assessment: Gathering, organizing, validating, and documenting data.
- Diagnosis: Identifying health problems and strengths.
- Planning: Establishing goals and interventions.
- Implementation: Carrying out the planned interventions.
- Evaluation: Evaluating the effectiveness of interventions.
Characteristics of the Nursing Process
- Client-centered
- Cyclic and dynamic (steps build on each other, not strictly linear)
- Universally applicable across the lifespan and settings.
Assessment
- Systematic and continuous collection, organization, validation, and documentation of data.
- Continuous process during all phases of the nursing process.
- Accurate and complete data collection is crucial for all phases.
Types of Assessment
- Initial Assessment: Performed soon after admission to healthcare agencies to create a complete database for problem identification and future comparisons. Example: Nursing admission assessment.
- Problem-focused Assessment: An ongoing process integrated with nursing care to determine the status of specific problems and identify new or overlooked ones. Example: Hourly assessment of fluid intake and output.
- Emergency Assessment: Performed during a physiologic or psychological crisis to identify life-threatening problems. Example: Rapid assessment of airway, breathing, and circulation during cardiac arrest.
- Time-lapsed Assessment: A reassessment made months after an initial assessment to compare current and baseline status. Example: Reassessment of patients in outpatient settings after discharge.
Components of Nursing Health History
- Biographical Data: Name, age, gender, marital status, occupation, religion, education, income.
- Chief Complaint: Patient's response to "What brought you to the hospital/clinic?" Recorded in their own words.
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History of Present Illness:
- Onset: When symptoms started
- Pattern of onset: Gradual or sudden
- Setting: Place where the symptoms started
- Severity: Mild, moderate, or severe
- Location: Where the symptom is
- Quality: Characteristics of the problem
- Radiation: Areas to which the symptom spreads
- Duration: How long the symptom has lasted
- Palliative factors: Factors reducing the symptoms
- Aggravating factors: Factors worsening the symptoms
- Associated symptoms: Other symptoms linked to the main one.
- Past History: Childhood illnesses, immunizations, allergies, accidents, and injuries, previous hospitalizations.
- Family History: Relevant family medical history. Example: family history of asthma , MI
- Lifestyle: Personal habits like substance use, diet, sleep patterns, hobbies, daily activities.
Types of Data
- Subjective Data (Symptoms): Information that only the patient can describe and verify. Example: "I feel pain in my chest."
- Objective Data (Signs): Measurable information that can be observed and documented by a healthcare professional. Example: Blood pressure, skin color, vomiting.
Sources of Data
- Primary Source: The client himself/herself.
- Secondary Source: Family members, records, lab reports, diagnostic findings, and healthcare providers
Data Collection Methods
- Observing Data using the senses (e.g., vision, smell, hearing, touch)
- Interviewing Structured communication to gather information.
- Examining Physical assessment techniques.
Organizing Data
- Nursing and non-nursing models (e.g., Maslow's hierarchy of needs, body systems models)
Stages of Interview
- Opening: Introducing yourself, explaining the purpose.
- Body: Gathering information through questioning.
- Closing: Summarizing, thanking the patient, any further plans.
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