Nursing Assessment Phases Quiz

Communication During the Interview

• Nonverbal Communication:
  • Appearance: Ensure professional appearance
  • Demeanour: Display poise when entering the room
  • Facial Expression: Keep expression neutral and friendly
  • Attitude: Maintain a non-judgmental attitude
  • Silence: Allow time for reflection and organization of thoughts
  • Listening: Maintain good eye contact, smile, and display an open, appropriate facial expression
• Verbal Communication:
  • Open-ended questions: Used to elicit feelings and perceptions

Documentation

• Includes:
  • Name, medical record number, age, date, time, probable medical diagnosis, chief complaint, and source of information (two patient identifiers)
• Past medical history:
  • Prior hospitalizations and major illnesses and surgeries
• Assess pain:
  • Location, severity, and use of a pain scale
• Allergies:
  • Medications, foods, and environmental; nature of the reaction and seriousness
• Medications:
  • Confirm accuracy of list, names, and dosages of medications
• Valuables:
  • Record and send to appropriate safe storage or send home with family
• Rights:
  • Orient patient, caregivers, and family to location, rights, and responsibilities
  • Goal of admission and discharge goal

Documenting Data

• Computer-based documentation systems:
  • Link to other documents and health care departments
• Electronic Medical Records (EMR):
  • Supplied by physicians for medical diagnoses and prescribed treatments
• Electronic Health Records (EHR):
  • Comprehensive health status of the client (emotional, physical, social, spiritual)
• Three types of assessment forms:
  1. Initial assessment form (nursing admission or admission database)
  2. Frequent or ongoing assessment forms (e.g., vital sign sheet, assessment flow chart)
  3. Focused or specialized assessment forms (e.g., pain scale chart, Braden scale chart)

Preparing for the Examination

• Preparing the physical setting:
  • Comfortable, warm room temperature
  • Private area free of interruptions
  • Quiet area free of distractions
• Examination tools:
  • Penlight
  • Mirror
  • Metric ruler
  • Magnifying glass
  • Wood's light

Validating Assessment Data

• Steps of validation:
  1. Deciding whether data require validation
  2. Determining ways to validate the data
  3. Identifying areas for which data are missing
• Methods of validation:
  1. Recheck through a repeat assessment
  2. Validate through comparison with objective data

Types of Questions

• Open-ended questions:
  • Begin with "how" or "what"
  • Example: "How have you been feeling lately?"
• Closed-ended questions:
  • Begin with "when" or "did"
  • Example: "When did your headache start?"
• Laundry list:
  • Provide a list of words for the client to choose from
• Rephrasing:
  • Clarify information and reflect on what was said
  • Example: "You are thinking that you have a serious illness?"
• Inferring:
  • Elicit the most accurate data possible from the client

Complete Health History

• Lays the groundwork for identifying nursing problems and provides a focus for the physical examination
• Has eight sections, which can be modified or shortened when necessary