, o Use attentive listening and other therapeutic
communication techniques that encourage a patient to tell
his or her story.
3. Terminating an Interview
o Termination of an interview requires skill. You summarize
your discussion with a patient and check for accuracy of the
information collected. Give your patient a clue that the
interview is coming to an end. For example, say, “I have
just two more questions. We'll be finished in a few more
minutes.”
o This helps a patient maintain direct attention without being
distracted by wondering when the interview will end.
Methods of obtaining data
An assessment is necessary for you to gather information to make
accurate judgments about a patient's current condition. Your
information comes from:
The patient through interview, observations, and physical
examination.
Family members or significant others' reports and response to
interviews.
Other members of the health care team.
Medical record information (e.g., patient history, laboratory work,
x-ray film results, multidisciplinary consultations).
Scientific and medical literature (evidence about disease
conditions, assessment techniques, and standards).
Subjective Data
Subjective data are your patients' verbal descriptions of their health
problems. For example, Mr. Lawson's self-report of pain at the
area where his incision slightly separated is an example of
subjective data. Subjective data include patients' feelings,
perceptions, and self-report of symptoms.
Only patients provide subjective data relevant to their health
condition. The data often reflect physiological changes, which you
further explore through objective review of body systems.
Objective Data
Objective data are observations or measurements of a patient's
health status. Inspecting the condition of a surgical incision or
wound, describing an observed behavior, and measuring blood
pressure are examples of objective data.
, Objective data is measured on the basis of an accepted standard
such as the Fahrenheit or Celsius measure on a thermometer,
inches or centimeters on a measuring tape, or a rating scale (e.g.,
pain).
When you collect objective data, apply critical thinking intellectual
standards (e.g., clear, precise, and consistent) so you can correctly
interpret your findings.
o Diagnosis
Identify components of the nursing diagnostic statement
The diagnostic reasoning process involves using the assessment
data you gather about a patient to logically explain a clinical
judgment, in this case a nursing diagnosis.
The diagnostic process flows from the assessment process and
includes decision-making steps. These steps include data
clustering, identifying patient health problems, and formulating the
diagnosis.
Identify assessment findings, goals, interventions, evaluations appropriate
to a specific nursing diagnosis.
Be able to recognize the difference between each category.
Context clues like “The Patient will…” means it is a goal.
o Planning
Components of goal/outcome statement
A patient-centered goal reflects a patient's highest possible level of
wellness and independence in function. It is realistic and based on
patient needs, abilities, and resources. A patient-centered goal or
outcome reflects a patient's specific behavior, not your own goals
or interventions.
Goals and expected outcomes direct your nursing care. Once you
set a patient-centered goal for a nursing diagnosis, the expected
outcomes provide the desired physiological, psychological, social,
developmental, or spiritual responses that indicate resolution of the
patient's health problems.
Usually you develop several expected outcomes for each nursing
diagnosis and goal. For a patient to resolve a goal, several
measurable outcomes are needed to ensure that the goal is met. In
the case of Mr. Lawson's diagnosis of Risk for Infection, Tonya
knows that more than one outcome is needed to ensure that the
patient is infection free.
,
The SMART acronym (Specific, Measurable, Attainable, and
Realistic, Timely) is a useful approach for writing goals and
outcome statements more effectively.
o Implementation
Independent nursing interventions
Nurse-initiated interventions are the independent nursing
interventions or actions that a nurse initiates without supervision or
direction from others.
Examples include positioning patients to prevent pressure ulcer
formation, instructing patients in side effects of medications, or
providing skin care to an ostomy site. Independent nursing
interventions do not require an order from another health care
provider.
Dependent nursing interventions
Health care provider–initiated interventions are dependent nurs-ing
interventions, or actions that require an order from a health care
provider. The interventions are based on the health care provider's
response to treating or managing a medical diagnosis.
Advanced practice nurses who work under collaborative
agreements with physicians or who are licensed independently by
state practice acts are also able to write dependent interventions.
As a nurse you intervene by carrying out the health care provider's
written and/or verbal orders. Administering a medication,
implementing an invasive procedure (e.g., inserting a Foley
catheter, starting an intravenous [IV] infusion) and preparing a
patient for diagnostic tests are examples of health care provider-
initiated interventions.
Direct care activities
Direct care interventions are treatments performed through
interactions with patients. For example, a patient receives direct
intervention in the form of medication administration, insertion of
a urinary catheter, discharge instruction, or counseling during a
time of grief.
Indirect care activities
Indirect care interventions are treatments performed away from a
patient but on behalf of the patient or group of patients (e.g.,
managing a patient's environment [e.g., safety and infection
control]), documentation, and interdisciplinary collaboration.
o Evaluation
Elements of the evaluation process
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