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Types of Questions used in Interviews o Open-ended—allow patient to verbalize freely o Closed—elicit specific information o Validating—validate what is heard o Clarifying—avert misconceptions o Reflective—encourage patient to elaborate on thoughts and feelings o Sequencing—place events in chronological order o Directing—obtain more patient information 9. SDA don’t eat pork) Patient Interview- how a history is obtained Preparatory Phase: reading past records that are available Introductory Phase: state name and status, identify purpose of interview, and clarify roles of nurse and patient (i.e. My name is Lisa Gray and I’ll be your student nurse. ” ) Working Phase: nurse gathers all the information needed to form the subjective database.Plan patient assessments by identifying assessment priorities and structuring the data to be collected systematically. Identify common problems encountered in data collection, noting their possible cause. Right now I’d like to ask you a few questions about yourself so that we can plan your nursing care together. Termination: tell them interview is done, what to expect next, when will contact be re-established, can I do anything else for you before I go?
o Set priorities o Individualize care that maximizes outcome achievenment o Facilitate communication among nurse team o Promote continuity o Coordination o Evaluate patients response to care o Create a record that can be used for evaluation, research etc o Promote nurses professional development o Which problems require my immediate attention or that of the team?
Which problems are my responsibility, and which should I refer to someone else? o Makes more sense to deal w medical problems first bc if they can be resolved than human response problems will go to…
o If its not life threatening, the nurse should meet the needs the patient thinks are most important (i.e.
a mom doesn’t want any baths done until she calls home; SO CALL HOME ) o Consider potential effects of assigning low priority to a diagnosis that may result in harmful future consequences…
Bathing/Hygiene Self-Care Deficit related to fear of falling in tub and obesity)OR written as a three part statement that also includes the problem’s defining characteristics: (i.e. Actual: problem that has been validated by the presence 2.
Bathing/Hygiene Self-Care Deficit related to fear of falling in tub and obesity, as manifested by strong odor and urine odor, unclean hair, statement of fearing fall in tub , and height and weight, 5’4, 170 lb) o Write in legally advisable terms o Nonjudgmental language o Make sure problem statement includes what is unhealthy or what wants to be enhanced o Avoid using defining characteristics, medical diagnoses or something that cant be changed in problem statement o Identify strengths patient can use to resolve health problems 6. Allows patients to be me informed and willing participants in their own care (validate diagnoses and assist in prioritization) 3.Improved communication (if diagnoses is accurate) and accountability 4. Conclusion: Avoid labeling patients in a way that objectifies them or limits the potential range of nurse patient interactions Pg.258 KEY TERMS actual nursing diagnoses collaborative problems : PRIMARY RESPONSIB.Helps define domain of nursing for health care admins , legislators etc. Define curriculum content, direct specialization and advancement and nursing and nursing research 6. Limits originality and ability to think things through 8. certain physiologic complications that nurses monitor to detect onset or changes in status. used by health care professionals Intuitive Problem Solvingunderstanding of a situation based on background, knowledge and skill Developing Cognitive Skills Critical thinking: a systematic way to form and shape one’s thinking. Describe the purpose of nursing observation, interview, and physical assessment. Determine patient’s current responses (physical and emotional) 2. Diagnosis (According to Gebbie and Lavin later on) The Nursing Process TODAY (ANA Congress for Nursing Practice) 1. Diagnosis (actual and potential health problems) 3. NOT RECOMMENDED can harm patient Scientific Problem Solvinghypothesis etc…Initiating actions and referrals in a timely way to ensure qualified treatment is given 4.Describe the four steps involved in data interpretation and analysis. Recognize Patterns or Clusters o Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue 2. Identifying Potential Complications o Prevent potential complications or make sure they’re detected early and managed 4.Feel free to respond only to those questions you feel comfortable answering, and know that your responses will be treated confidentially by the staff. Types of Questions Used in Interview o o o o o o o Open-ended: allow patients to speak freely Closed: SPECFIC Validating: validate what you heard Clarifying: avoid misconceptions Reflective: encourage patient to elaborate on thoughts and feelings Sequencing: place events in chrono order Directing: obtain more patient info follow up….Is it bc they lack knowledge, or are they in denial and unable to cope w medical diagnosis).Obtain a nursing history using effective interviewing techniques. KEY TERMS Assessing: systematic, dynamic and CONTINOUS collections, validation, analysis and communication of patient data cue: indicator something is wrong (patient doesn’t respond when talking on the right side) data: information database: pertinent patient info collected by the nurse and other healthcare professionals emergency assessment focused assessment inference: judgment you reach about cue (i.e.o Focus on patient o Actively listen o Ask about main problems first o Pose questions and comments in appropriate manner o Avoid comments and questions that impede communication o Use silence and touch appropriately 8. he has an hearing impairment)MUST BE VALIDATED via physical exams, clarifying statements or sharing inferences w others initial assessment Establish Assessment Priorities o Think carefully about data type needed to develop a satisfactory plan of care o Don’t collect or repeat irrelevant data (data that is not a priority) o Spend time on more important data Systematically Structuring Data collection o Minimum data set: the minimum data that must be collected from each patient Data Collection o Subjective Data: info perceived only by AFFECTED PERSON o Objective Data: observable and measurable o Pay attention to both promotes critical thinking bc they may validate each other ok o Be purposeful, complete, accurate, factual and relevant Problems Related to Data Collection o Inappropriate organization of database o Pertinent data withheld o Irrelevant or Duplicated Data o Misinterpreted o Failure to update database o Interpretation of data recorded and not observed behavior (bias/opinion) Nursing History Focuses on: o patient’s strengths and weaknesses o health risks, such as hereditary and environmental factors; o potential and existing health problems Components: o o o o o Profile Reason for seeking healthcare Normal health habits Development history, family history Cultural consideration in decision making etc (i.e.