c. Patient record: A review of the records prepared
by different members of the healthcare team pro-
vides information essential to comprehensive
nursing care.
d.Medical history, physical examination, and
progress notes: Sources that record the findings
of physicians as they assess and treat the patient.
e.Reports of laboratory and other diagnostic studies:
These sources (e.g., x-rays and diagnostic tests)
can either confirm or conflict with data collected
during the nursing history or examination.
f. Reports of therapies by other healthcare profes-
sionals: Other healthcare professionals record
their findings and note progress in specific areas
(e.g., nutrition, physical therapy, or speech
therapy).
g.Other healthcare professionals: Other nurses,
physicians, social workers, and so on can provide
information about a patient’s normal health
habits and patterns and response to illness.
h.Nursing and other healthcare literature: If a nurse
is unfamiliar with a disease, it is important for
him/her to read about the clinical manifestations
of the disease and its usual progression to know
what to look for when assessing the patient.- a.Purposeful: The nurse must identify the purpose
of the nursing assessment (comprehensive,
focused, emergency, time-lapsed) and then
gather the appropriate data.
b.Complete: All patient data need to be identified to
understand a patient’s health problem and develop
a plan of care to maximize health promotion.
c. Factual and accurate: Nurses concerned with
accuracy and fact must continually verify what
they hear with what they observe using other
senses and validate all questionable data.
d.Relevant: Because recording data can become
an endless task, nurses must determine what
type of data and how much data to collect for
each patient.
4.Sample answers:
a.What are the patient’s current responses to
his/her situation?
b.What is the patient’s current ability to manage
his/her care?
c. What is the immediate environment? - a.Patient should know the name of his/her primary
nurse and what he/she can expect of nursing.
b.Patient should sense that the nurse is competent
and cares about him/her.
c. Patient should know what is expected of
him/her in terms of developing the plan of care
and participating in its execution.
6.Sample answers:
a.Closed questions:
How long have you been experiencing these
symptoms?
How many children do you have at home?
b.Open-ended questions:
How will you modify your diet now that you
have been diagnosed with diabetes?
What do you know about insulin injections?
c. Reflective questions:
What effect will diabetes have on your life?
How do you feel about using insulin injections
to control your diabetes?- a.Patient’s health orientation: Patients must iden-
tify potential and actual health risks and explore
habits, behaviors, beliefs, attitudes, and values
that influence levels of health.
b.Patient’s developmental stage: Nursing assessments
are modified according to the patient’s develop-
mental stage.
c. Patient’s need for nursing: Whether the nurse
will interact with the patient for a short or long
period and the nature of nursing care needs
influence the type of data the nurse collects.
8.Sample answers:
a.When there are discrepancies (e.g., a patient
claims he has no pain but grimaces when you
touch his chest)
b.When the data lack objectivity (e.g., when a
patient claims to have 20/20 vision but holds his
reading material far away from his face)
9.Immediate communication of data is indicated
whenever assessment findings reveal a critical
change in the patient’s health status that
necessitates the involvement of other nurses or
healthcare professionals.
REFLECTIVE PRACTICE USING CRITICAL
THINKING SKILLS
Sample Answers
1.How might the nurse facilitate Ms. Morgan’s ability
to cope with disability?
The nurse should assess the patient’s body image
and self-esteem needs. Working collaboratively with
other members of the healthcare team, the nurse
could then prepare a nursing care plan that specifi-
cally addresses these needs.
2.What would be a successful outcome for this patient?
By discharge, Ms. Morgan will verbalize acceptance
of her diagnosis of MS and state methods to keep
herself as physically active as possible.
3.What intellectual, technical, interpersonal, and/or
ethical/legal competencies are most likely to bring
about the desired outcome?
Intellectual: knowledge of the signs and symptoms
of MS and supportive services for patients with MS
Interpersonal: demonstration of strong people skills
for dealing with individuals experiencing
alterations in health
Ethical/Legal: strong advocacy skills and a willing-
ness to use them for patients needing assistance
4.What resources might be helpful for Ms. Morgan?
Family counseling, printed materials on MS, support
groups
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