The Nursing Process
This is the first step of the nursing process, where a nurse gathers subjective and objective data about the patient
What is assessment
This type of database provides a comprehensive assessment of the patients overall health and is typically collected during the initial visit creating a baseline This database is used to monitor progress or changes in a condition over time, such as treatment or after a hospital stay
What is follow-up database
This type of question is commonly used during the nursing interview, encouraging patients to provide detailed open ended responses
What is open ended questions
This section of the health history provides information about hereditary conditions, genetic predispositions, and disease that may affect the patient
What is family history
This type of data is gathered through observations, physical exams, and measurable findings, such as vital signs or lab results
What is objective data
In this step, nurses establish measurable goals and determine interventions to address the identified problems
What is planning
This database focuses on a specific issue or concern, such as pain or a particular symptom, and is used in short term care situations
What is focused database
This form of communication includes body language, facial expressions, eye contact, and gestures
What is non-verbal communication
This part of the health history involves evaluating symptoms and concerns by body systems, including ENT, urinary, cardiac, and more
What is the review of systems
This method helps nurses prioritize patient care by adressing these three critical areas to ensure survival
What is airway, breathing, circulation (ABC)
This step assess whether the patients goals have been met and determines if the care plan needs modification
What is evaluation
This type of database is collected quickly in life-threatening situations, focusing on immediate and critical information
What is emergency database
This age group requires a focus on interviewing them alone, while emphasizing respect, honesty, and confidentiality
What is adolescents
This part of the health history uses tools like OPQRSTU to explore the characteristics of the chief complaint
In Maslow's hierarchy, these needs such as food, water, warmth, and rest are found at the foundation of the pyramid
What is physiological/ basic needs
This step involves putting the care plan into action to achieve desired outcomes
What is implementation
This type of database provides a comprehensive assessment of the patients overall health and is typically collected during the initial visit creating a baseline
What is complete database
This communication skill involves validating a patients feeling, helping you build trust and rapport during an interview
What is empathy
This section of the health history includes identifying information such as name, DOB, and marital status
What is biographical data
This approach to nursing uses current research, clinical expertise, and is literature reviewed and is often referred to as the "gold standard" of care
what is evidence-based practice
If patients goals are not met, the nurse preforms this action to modify the care plan or establish new goals
What is reassess and revise the care plan
This database type is used to reassess both acute and chronic problems to determine effectiveness of interventions or the progression of the condition over time
What is follow-up database
This common communication mistake, involving the use of medical or technical terms, can confuse patients and hinder understanding during and interview
What is using jargon
This part of the health history examines personal and social factors, including ADL's, diet, sleep patterns, habits, and stress
What is functional assessment
Using these professionals ensures accurate communication with patients who speaks a different language reducing errors and maintaining confidentiality
What are medically trained translators