PRELIMS H.A

• The Nursing Process (ADPIE)

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Assessment


  Gathering information
• Types of data in assessment

  • Subjective data (what the patient tells the nurse)
  • Objective data (data the nurse obtains through assessment or observation)
• Subjective data


  Sensations, symptoms, feelings, sadness, perceptions, desires that can only be elicited and verified by the client
• Objective data


  Data the nurse obtains through their assessment or observation (e.g. vital signs)
• Diagnosis


  Interpret the information/data collected
• Planning


  Set goals to solve the problems/prioritize the outcomes of care
• SMART goals


  • Specific
  • Measurable
  • Achievable
  • Relevant
  • Time frame
• Implementation


  Reaching goals through performing nursing actions
• Evaluation


  Determine the outcomes of goals
• Types of assessment


  • Initial comprehensive assessment
  • Ongoing/partial assessment
  • Focused/problem oriented assessment
  • Emergency assessment
• Initial comprehensive assessment


  Involves the collection of subjective data about the client's health perception of all body parts
• Ongoing/partial assessment


  Data collection that occurs after the comprehensive data base is established, consisting of a mini overview of the client's body system and holistic health patterns
• Focused/problem oriented assessment


  Does not replace the comprehensive assessment
• Emergency assessment


  A very rapid assessment performed in life threatening situations
• Sign


  An abnormality detected through physical examination and laboratory studies
• Symptom


  A subjective sensation that patients feel from disorders
• Interview


  A purposeful conversation between the nurse and the patient
• Phases of the interview

  • Introductory phase (orientation phase)
  • Working phase (maintenance phase)
  • Summary/closing phase (termination phase)
• Introductory phase


  Introduction, introduce self by name, position
• Working phase


  Nurse elicits the client's comment about biographic data
• Summary/closing phase


  The nurse summarizes information obtained during the working phase and validates problems and goals with clients
• Types of communication


  • Non-verbal
  • Verbal
• Non-verbal communication


  • Appearance
  • Demeanor
  • Facial expression
  • Attitude
  • Silence
  • Listening
• Appearance


  Nurse must have a professional appearance
• Demeanor


  Nurse must display poise/focus on the client
• Facial expression


  Always overlooked, keep expression neutral and friendly
• Attitude


  Most important non-verbal skill to develop as a healthcare professional
• Silence


  Periods of silence allow you and the client to reflect and organize thoughts
• Listening


  Become an effective listener, takes concentration and practice
• Verbal communication


  • Open-ended questions
  • Closed-ended questions
  • Laundry list
  • Rephrasing
  • Inferring
  • Providing information
• Open-ended questions


  May help to reveal significant data about the client's health status
• Closed-ended questions


  To obtain facts and focus on specific information, clients can respond with one or two words
• Laundry list


  Provide the client with a choice of words to choose from in describing symptoms, conditions or feelings
• Rephrasing


  Rephrasing information the client has provided is an effective way to communicate during the interview
• Inferring


  Inferring information from what the client tells you and what you observe in the client's behavior may elicit more data or verify existing data
• Providing information


  Make sure you answer every question as well as you can
• Special considerations during the interview

  • Gerontologic variations in communication
  • Cultural variations in communication
  • Emotional variations in communication
• Gerontologic variations in communication


  Normal aspect of aging, do not necessarily equate with a health problem, assess hearing activity of elders
• Cultural variations in communication


  Ethnic cultural variations in communication and self, frequently noted variations in communication styles