Notes from textbook reading

Question 1

ADPIE

Answer 1

Assessment, diagnosis, Planning, implementation, evaluation

Question 2

types of health assessment

Answer 2

1. initial comprehensive assessment
2. ongoing or partial assessment
3. focused or problem-oriented assessment
4. emergency assessment

Question 3

Steps of health assessment

Answer 3

• collection of subjective data
• collection of objective data
• validation of data
• documentation of data

Question 4

Initial Comprehensive Assessment

Answer 4

involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a step-by-step physical examination.

Question 5

Ongoing or Partial Assessment

Answer 5

consists of data collection that occurs after the comprehensive database is established. This consists of a mini overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data

Question 6

Focused or Problem-Oriented Assessment

Answer 6

does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not address areas not related to the problem.

Question 7

Emergency Assessment

Answer 7

very rapid assessment performed in life-threatening situations (Fig. 1-4). In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.

Question 8

What are types of subjective data?

Answer 8

• Biographical information (name, age, religion, occupation, etc.)
• History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen)
• Personal health history
• Family history
• Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)
• Review of systems

Answer 9

• Physical characteristics (e.g., skin color, posture)
• Body functions (e.g., heart rate, respiratory rate)
• Appearance (e.g., dress, hygiene)
• Behavior (e.g., mood, affect)
• Measurements (e.g., blood pressure, temperature, height, weight)
• Results of laboratory testing (e.g., platelet count, x-ray findings)

Question 10

Process of Data Analysis

Answer 10

1. Identify abnormal cues and supportive cues.
2. Cluster cues.
3. Draw inferences and identify and prioritize client concerns.
4. Propose possible collaborative problems to notify primary care provider.
5. Identify need for referral to primary care provider.
6. Document conclusions.

Question 11

Nonverbal communication to avoid during interviews

Answer 11

• excessive or insufficient eye contact
• distraction and distance
• standing

Question 12

Verbal communication to avoid during interviews

Answer 12

• biased or leading questions
• rushing through the interview
• reading the questions

Question 13

What are open-ended questions?

Answer 13

Open-ended questions are used to elicit the client’s feelings and perceptions. They typically begin with the words “how” or “what.” An example of this type of question is: “How have you been feeling lately?”

Question 14

Closed-Ended Questions

Answer 14

Use closed-ended questions to obtain facts and to focus on specific information. The client can respond with one or two words. Closed-ended questions typically begin with the words “when” or “did.” An example of this type of question is: “When did your headache start?”

Question 15

When interacting with an anxious client

Answer 15

• Provide the client with simple, organized information in a structured format.
• Explain who you are, along with your role and purpose.
• Ask simple, concise questions.
• Avoid becoming anxious like the client.
• Do not hurry, and decrease any external stimuli.

Question 16

WHEN INTERACTING WITH AN ANGRY CLIENT

Answer 16

• Approach this client in a calm, reassuring, in-control manner.
• Allow them to ventilate feelings. However, if the client is out of control, do not argue with or touch the client.
• Obtain help from other health care professionals as needed.
• Avoid arguing and facilitate personal space so that the client does not feel threatened or cornered.
• Never allow the client to position themselves between you and the door.

Question 17

When interacting with a depressed client

Answer 17

• Express interest in and understanding of the client and respond in a neutral manner.
• Do not try to communicate in an upbeat, encouraging manner. This will not help the depressed client.

Question 18

When interacting with a manipulative client

Answer 18

• Provide structure and set limits.
• Differentiate between manipulation and a reasonable request.
• If you are not sure whether you are being manipulated, obtain an objective opinion from other nursing colleagues.

Question 19

When interacting with a seductive client

Answer 19

• Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors.
• Encourage client to use more appropriate methods of coping in relating to others.
• If the overt sexuality continues, do not interact without a witness.
• Report inappropriate behavior to a supervisor.

Question 20

When discussing sensitive issues (ex. sexuality, dying, spirituality)

Answer 20

• First, be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality; then recognize that these factors may affect the client’s health and may need to be discussed with someone.
• Ask simple questions in a nonjudgmental manner.
• Allow time for ventilation of client’s feelings as needed.
• If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate, for example, to a pastoral counselor for spiritual concerns or other specialists as needed.

Question 21

Eight sections of a complete health history

Answer 21

Biographical data
Reasons for seeking health care
History of present health concern
Personal health history
Family health history
ROS for current health problems
Lifestyle and health practices profile
Developmental level

Question 22

COLDSPA

Answer 22

1. Character
2. onset
3. location
4. duration
5. severity
6. pattern
7. associated factors/how it affects the client

Question 23

character

Answer 23

Describe the sign or symptom (feeling, appearance, sound, smell, or taste if applicable).

“What does the pain feel like?”

Question 24

onset

Answer 24

When did it begin?

“When did this pain start?”

Question 25

Location

Answer 25

Where is it? Does it radiate? Does it occur anywhere else? “Where does it hurt the most? Does it radiate or go to any other part of your body?”

Question 26

duration

Answer 26

How long does it last? Does it recur? “How long does the pain last? Does it come and go or is it constant?”

Question 27

severity

Answer 27

How bad is it? How much does it bother you? “How intense is the pain? Rate it on a scale of 1–10.”

Question 28

pattern

Answer 28

What makes it better or worse? “What makes your back pain worse or better? Are there any treatments you’ve tried that relieve the pain?”

Question 29

Associated factors/how it affects the client

Answer 29

What other symptoms occur with it? How does it affect you? “What do you think caused it to start? Do you have any other problems that seem related to your back pain? How does this pain affect your life and daily activities?”