Chapter 4 For an in-depth study of basic nursing assessments, consult the following publications: Lewis SM, et al: Medical-surgical nursing, ed 8, St. Louis, 2011, Mosby. Nugent P, Green J, Hellmer Saul MA, Pelikan P: Mosby’s comprehensive review of nursing for the NCLEX-RN examination, ed 20, St. Louis, 2012, Mosby. Potter PA, Perry AG, Stockert PA, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby. Weilitz P, Potter PA: Pocket guide for health assessment, ed 6, St. Louis, 2007, Mosby. Open-ended questions: “How can I help you?” Summarizing statements: “Coughing and wheezing seem to be your concerns.” Reflective statements: “You seem out of breath.” Leading questions: “Is your sputum green?” Focused questions: “Are you short of breath now?” Clarification: “When did you last take you inhaler?” Restating: “So you said your shortness of breath became worse yesterday?” Include introductory information, such as: Information about the country can be important: • What is the cultural or ethnic affiliation? • In what country was the patient born? • How many years has he or she been in the United States? • Does the patient need an interpreter (what language)? • Does the patient need a communication tool (language board)? • Could the patient use telephone language line (available through most local telephone companies)? Assess for cultural practices: • Are there special rituals that may need to be honored? • Are there special health practices that may need to be honored? • How will the illness affect cultural practices? Include introductory information, such as: Assess for potential religious supports: • Minister, priest, rabbi, shaman, emmen, other • The need for church or prayer services • The need for confession, communion, religious music Assess for religious practices: • Are there special rituals that may need to be honored? • Are there special health practices that may need to be honored? • Are there special religious dietary needs? • Is there a special prayer schedule that should be followed? • Are there special fasting rituals that should be followed? • How will the illness affect religious practices?
Basic Nursing Assessments
The Patient Interview
Functional Assessment
Interviewing Strategies
Cultural Assessment
Spiritual Assessment
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Basic Nursing Assessments
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