Chapter 5: Assessment, Nursing Diagnosis, Planning
What is "the interview" defined as during an assessment?
Based on gathering data - not a social interaction.
-Good communication is crucial: could be verbal or nonverbal.
-3 stages include the opening, the body, and the closing.
When nursing interventions and/or orders are carried out, this is what phase of the nursing process?
Implementation
What MUST you do after each intervention is completed?
Document. Document. Document!
Always document each intervention. If it's not documented, it was not done (even if you did it).
What are two ways to communicate?
Verbal and Nonverbal
Name 1 mode of learning.
-Visual: Through what you see
-Auditory: Through what you hear
-Kinesthetic: By performing a task or handling items
Define objective date and subjective data. Provide 1 example of each.
Objective data is measurable, observable, and verifiable information. This is quantified data.
Example: Vital signs
Subjective date is information a patient reports about their feelings, symptoms, and personal experiences. This is qualitative data.
Example: Pain level
Mnenomic: Objective -> Observation ; Subjective -> Self
What are you evaluating during the evaluation phase?
Evaluating for effectiveness in reaching the patient's goals or outcomes
Name 1 purpose of documentation.
-Provides a written record of the history, treatment, care, and response of the patient while under the care of a health care provider
-Is a guide for reimbursement of costs of care
-May serve as evidence of care in a court of law
-Shows the use of the nursing process
-Provides data for quality assurance studies
-Is a legal record that can be used as evidence of events that occurred of treatments given
-Contains observations by the nurses about the patient's condition, care, and treatment delivered
-Shows progress toward expected outcomes
Name 1 factor affecting communication.
-Cultural differences
-Past experiences
-Emotions/Mood
-Attitude of the individual
Name 1 special consideration for teaching the elderly.
-Provide good lighting
-Provided printed teaching materials in large type
-Encourage patient to wear glasses if needed
-Encourage patient to wear and adjust hearing aids
-Use short sentences and pause frequently
-Keep medical terms to a minimum
-Ask questions at frequent intervals
During a physical assessment, you follow the techniques of inspection, palpation, percussion, and auscultation.
When completing an abdominal assessment, which order of techniques of inspection do you follow?
Inspection, Auscultation, Palpation, and Percuss
-You want to listen to bowel sounds before manipulating the abdomen as palpating or percuss can interfere with bowel sounds.
What should you consider when determining the order of patient care to complete?
Priority setting/Prioritization
How would you write out 7am and 7pm in military time?
7am - 0700
7pm - 1900
Name 1 way to communicate with the hearing-impaired.
-Speak very distinctly
-Do not shout
-Speak slowly
-Get the person's attention
-Maintain a good distance (2 1/2 to 4 feet)
-Watch for nonverbal feedback
-Use short sentences
-Paraphrase for clarification
Do you document patient education provided?
YES!
Nurse's notes should include specific instructions taught, method of teaching, and evidence of evaluation with specific results.
Complete a head-to-toe assessment on one of your classmates.
Great job!
Who constructs a nursing care plan? What if that individual is not available?
RN may construct the initial nursing care plan.
If patient is admitted and RN is not available, LPN/LVN may construct preliminary nursing care plan that an RN will review and validate as needed the following day.
What is wrong with the following Narrative charting?
10/29/2026 1500 - Patient appears in pain. Patient reports a pain level of 8 on a 1-10 pain scale.
10/29/2026 1515 - Administered Tylenol 500mg.
10/29/2026 1545 - Patient reports a pain level of 4 on a 1-10 pain scale. Patient states "I feel a bit better."
Including personal subjective data. Avoid inputting your own judgement. Subjective data should come from the patient especially when it comes to pain.
Missing medication route: how was it administered?
Missing signature: Who completed the note?
Name 2 therapeutic communication techniques.
-Promoting communication between sender and receiver, obtaining feedback
-Focusing on the communicator
-Using silence and open-ended questions
-Restating the message
-Clarifying
-Using therapeutic touch
Patient education/teaching begins when? And ends when?
At the time of admission and continues until discharge.
Case Study: Mr. Jones is a 55 year old patient recently admitted for headaches that are worse with light and noisy environments. His latest BP was 140/88, HR 82, RR 18, SP02 95% on RA, 98.7F temporally. He reports a pain level of 6/10.
What is your assessment? What is one possible nursing diagnosis? What is your planning?
Assessment: Vital signs, pain level, focus on head assessment. Complete heart/lung/bowel sounds and extremities assessment.
Nursing Diagnosis: Acute pain r/t environmental factors as evidenced by verbal reports of elevated noise and sensitivity to light and reported pain level of 6/10.
Planning: Ensure room lighting is dimmed or to desired patient level. Provide pain medication as prescribed. Reduce noise around patient's room, move patient away from nurse's station to the quietest area if possible.
Case Study: Mr. Jones is a 55 year old patient recently admitted for headaches that are worse with light and noisy environments. His latest BP was 140/88, HR 82, RR 18, SP02 95% on RA, 98.7F temporally. He reports a pain level of 6/10.
What is your implementation? What is your evaluation?
Implementation: Provide room lighting that is dimmed or to desired patient level. Administer pain medication as prescribed. Move patient's room to a quiet area.
Evaluation: Assess pain level after administration of pain medication. Assess for any headaches.
A patient has a history of hypertension. Their latest BP reads 162/96, HR 82. You have parameters to administer antihypertensive medication for a BP >130/80. You administered antihypertensive medication. Upon re-check, patient's BP is 129/79.
What would your focus charting look like?
Three components: Data, Action, Response (DAR); Data, Action, Evaluation (DAE)
10/29/2026 1800
Problem: Elevated Blood Pressure
D. Patient with known medical history of HTN; BP 162/96, HR 82 -------
A. Administered antihypertensive based on parameters. Reviewed low salt diet.
R. After administration of antihypertensive medication, repeat BP 129/79. Patient verbalized understanding of dietary recommendation.
Your name, Credentials
A patient states, "I'm scared about my surgery tomorrow." What is the nurse's best response?
A. "There's nothing to worry about."
B. "Many people have surgery every day."
C. "Tell me more about what concerns you."
D. "The surgeon will discuss that with you."
C - "Tell me more about what concerns you."
This uses open ended communication to allow the patient to express their feelings without dismissing them.
A nurse is teaching a patient newly diagnosed with hypertension. Which statement by the patient indicates a need for further teaching?
A. "I will limit foods high in sodium."
B. "I will take my medication as prescribed."
C. "I can stop taking my medication when my blood pressure returns to normal."
D. "I will monitor my blood pressure regularly."
C - "I can stop taking my medication when my blood pressure returns to normal."
HTN is often a chronic condition with ongoing management. Patients with HTN should continue prescribed medications unless directed otherwise by their healthcare provider. So further education should be reinforced in this case.