NUR 216 EXAM 1- 4 STUDY GUIDE
What is Health Assessment? - Answers - Requires the use of: hearing, seeing,smelling
and touching
Nursing is a practice profession
Health assessment is an essential skill to nursing practice
A key goal of health assessment is to identify patient cure for normal and abnormal
findings
Person-centered care is the ultimate goal of health assessment
What is the definition of Health? - Answers - Health has different meaning for each
individual, family, community, and population
Nurse should have an understanding of each patient's definition of health
Cultural practices influence an individual's behavior to promote, maintain, and restore
health
Primary Prevention - Answers - Health promotion strategies limits exposure to
hazards,and risks and to make healthy lifestyle choices
Ex: annual physical exam, immunizations
Secondary Prevention - Answers - Early screenings, detection, and treatment of
diseases the ability to access early treatments
Ex: Colonoscopy to screen for colon cancer
Tertiary Prevention - Answers - Restoration of health after illness or disease to prevent
death and disability
Ex:Rehabilitation programs
Health Assessment is a Skill - Answers - Requires each nurse to be a detective, to
investigate everything reported by the patient
Need to be able to recognize and analyze cues, formulate hypotheses, generate
solutions and a plan of action
Assessing a patient requires using perceptual senses
Characteristics of Health Assessment - Answers - Collects, validates, and clusters data
to assess the whole patient.
Must be organized
Utilizes patient resources (pasta medical history, diagnostics, verbal, and written
reports)
Establish baseline information about the patient.
Identifies factors influencing health and well-being
Identifies normal and abnormal findings, relevant and irrelevant
Assessment - Answers - Is the first steps and requires the nurse collect and analyze
data
,(Physiological, psychological, psychosocial, economical, spiritual and cultural practices
and beliefs)
Diagnosis - Answers - Includes analyzing potential or actual health problems or needs
for the patient
Subjective & Objective data
Planning/Outcome - Answers - This involves working with the patient in care to meet the
needs incorporating short term and long term goals of the patient
SMART GOALS:Specific, Measurable, Achievable, Realistic, Timing
Implementation (Intervention) - Answers - Includes nursing and patient actions to meet
the goals of
Evaluation - Answers - This is ongoing process that assesses whether short or long
term goals have been met
Reevaluate and modifications if necessary
Critical Thinking (Reflective Thinking) - Answers - Involves collecting and analyzing
information and carefully considering options for action
Clinical Reasoning - Answers - Uses patient's history, physical signs, symptoms,
laboratory data, and diagnostic imaging.
Arrives at a diagnosis and formulates a treatment plan based on that information.
Clinical Judgment - Answers - Interpretation or conclusion about a patients needs,
concerns or health problems, and/or the decision to take action ( or not) use or modify
standard approaches, or improvise as one deems appropriate to the patients response
Intuitive Thinking - Answers - "Gut feeling" about what may be occurring in a patient
situation
Psychomotor - Answers - the "doing" process of assessment
Inspect
Percussion
Palpitation
Auscultation
The 4 techniques for physical assessment - Answers - Inspection
Palpation
Percussion
Auscultation
Patient Protection and Affordable Care Act (PPACA) - Answers - Provides high-quality,
safer, more affordable, and accessible care.
Nurses have a leading role in assessing, teaching, and advocating.
,Best Practice Assessment - Answers - Nursing research and evidence-based practice
guides assessments and clinical decisions to provide safe and effective care
Quality and Safety Education for Nurses (QSEN) identifies six core competencies
Therapeutic Communications - Answers - Focus on the client and foster the therapeutic
relationship
Listen actively
Maintain eye contact
Do not interrupt the patient
Dimensions of therapeutic, patient-centered assessment include - Answers - empathy
and compassion
unconditional regard
genuineness
respect
caring
Barriers to Communication - Answers - Leading the patient
Asking too many questions
Not allowing enough response time
Using medical jargon
Making assumptions
Taking response personally
Changing the subject inappropriately
Asking "why" questions
Giving advice
Stereotyping
Offering false reassurance
Using patronizing language
Communicating with patients with special needs - Answers - hearing impaired
visually impaired
aphasiac patients
cognitively impaired
aggressive or challenging patients
patient with a language barrier
patient with low health literacy
Cultural Considerations - Answers - Many cultures and religions have restrictions on:
Eye contact
Touching
Distance
Modesty
Opposite sex provider
, Open-ended questions - Answers - Allow the patient to express thoughts and
encourage verbalization, allowing the nurse to explore the focused topic more broadly.
Ex: how do you remember to take all of your medications?
Closed-ended questions - Answers - Clarify and focus on specific problems, limit
responses and are usually answered with one word responses such as yes or no
Ex: Do you weigh yourself daily?
Phase of interview - Answers - Introduction phase one:
Introduce yourself
Explain your role
Establish rapport and trust
Working phase two:
Collect data by using open- and closed-
ended questions
Patient tells his or her story and history
Summarization phase three:
Clarify and
summarize the
patient's self report
Restate the finding
Confirm the goal
Health History - Answers - Starts with the review of systems (ROS)
The ROS is a subjective report the patient gives about all body
systems
Patient may "report" or "deny" symptoms
Pertinent positives
Pertinent negatives
Types of Health History - Answers - comprehensive health assessment
focused or problem oriented
follow up history
Types of Data Sources - Answers - Primary Source: The patient
Secondary Source: Can be family members,
significant others, or medical records
*always establish reliability of the source
Taking a Health History - Answers - Provides a database about a patients past and
present health, and patients personal beliefs that influence health and illness.
Records subjective and essential data
What is Health Assessment? - Answers - Requires the use of: hearing, seeing,smelling
and touching
Nursing is a practice profession
Health assessment is an essential skill to nursing practice
A key goal of health assessment is to identify patient cure for normal and abnormal
findings
Person-centered care is the ultimate goal of health assessment
What is the definition of Health? - Answers - Health has different meaning for each
individual, family, community, and population
Nurse should have an understanding of each patient's definition of health
Cultural practices influence an individual's behavior to promote, maintain, and restore
health
Primary Prevention - Answers - Health promotion strategies limits exposure to
hazards,and risks and to make healthy lifestyle choices
Ex: annual physical exam, immunizations
Secondary Prevention - Answers - Early screenings, detection, and treatment of
diseases the ability to access early treatments
Ex: Colonoscopy to screen for colon cancer
Tertiary Prevention - Answers - Restoration of health after illness or disease to prevent
death and disability
Ex:Rehabilitation programs
Health Assessment is a Skill - Answers - Requires each nurse to be a detective, to
investigate everything reported by the patient
Need to be able to recognize and analyze cues, formulate hypotheses, generate
solutions and a plan of action
Assessing a patient requires using perceptual senses
Characteristics of Health Assessment - Answers - Collects, validates, and clusters data
to assess the whole patient.
Must be organized
Utilizes patient resources (pasta medical history, diagnostics, verbal, and written
reports)
Establish baseline information about the patient.
Identifies factors influencing health and well-being
Identifies normal and abnormal findings, relevant and irrelevant
Assessment - Answers - Is the first steps and requires the nurse collect and analyze
data
,(Physiological, psychological, psychosocial, economical, spiritual and cultural practices
and beliefs)
Diagnosis - Answers - Includes analyzing potential or actual health problems or needs
for the patient
Subjective & Objective data
Planning/Outcome - Answers - This involves working with the patient in care to meet the
needs incorporating short term and long term goals of the patient
SMART GOALS:Specific, Measurable, Achievable, Realistic, Timing
Implementation (Intervention) - Answers - Includes nursing and patient actions to meet
the goals of
Evaluation - Answers - This is ongoing process that assesses whether short or long
term goals have been met
Reevaluate and modifications if necessary
Critical Thinking (Reflective Thinking) - Answers - Involves collecting and analyzing
information and carefully considering options for action
Clinical Reasoning - Answers - Uses patient's history, physical signs, symptoms,
laboratory data, and diagnostic imaging.
Arrives at a diagnosis and formulates a treatment plan based on that information.
Clinical Judgment - Answers - Interpretation or conclusion about a patients needs,
concerns or health problems, and/or the decision to take action ( or not) use or modify
standard approaches, or improvise as one deems appropriate to the patients response
Intuitive Thinking - Answers - "Gut feeling" about what may be occurring in a patient
situation
Psychomotor - Answers - the "doing" process of assessment
Inspect
Percussion
Palpitation
Auscultation
The 4 techniques for physical assessment - Answers - Inspection
Palpation
Percussion
Auscultation
Patient Protection and Affordable Care Act (PPACA) - Answers - Provides high-quality,
safer, more affordable, and accessible care.
Nurses have a leading role in assessing, teaching, and advocating.
,Best Practice Assessment - Answers - Nursing research and evidence-based practice
guides assessments and clinical decisions to provide safe and effective care
Quality and Safety Education for Nurses (QSEN) identifies six core competencies
Therapeutic Communications - Answers - Focus on the client and foster the therapeutic
relationship
Listen actively
Maintain eye contact
Do not interrupt the patient
Dimensions of therapeutic, patient-centered assessment include - Answers - empathy
and compassion
unconditional regard
genuineness
respect
caring
Barriers to Communication - Answers - Leading the patient
Asking too many questions
Not allowing enough response time
Using medical jargon
Making assumptions
Taking response personally
Changing the subject inappropriately
Asking "why" questions
Giving advice
Stereotyping
Offering false reassurance
Using patronizing language
Communicating with patients with special needs - Answers - hearing impaired
visually impaired
aphasiac patients
cognitively impaired
aggressive or challenging patients
patient with a language barrier
patient with low health literacy
Cultural Considerations - Answers - Many cultures and religions have restrictions on:
Eye contact
Touching
Distance
Modesty
Opposite sex provider
, Open-ended questions - Answers - Allow the patient to express thoughts and
encourage verbalization, allowing the nurse to explore the focused topic more broadly.
Ex: how do you remember to take all of your medications?
Closed-ended questions - Answers - Clarify and focus on specific problems, limit
responses and are usually answered with one word responses such as yes or no
Ex: Do you weigh yourself daily?
Phase of interview - Answers - Introduction phase one:
Introduce yourself
Explain your role
Establish rapport and trust
Working phase two:
Collect data by using open- and closed-
ended questions
Patient tells his or her story and history
Summarization phase three:
Clarify and
summarize the
patient's self report
Restate the finding
Confirm the goal
Health History - Answers - Starts with the review of systems (ROS)
The ROS is a subjective report the patient gives about all body
systems
Patient may "report" or "deny" symptoms
Pertinent positives
Pertinent negatives
Types of Health History - Answers - comprehensive health assessment
focused or problem oriented
follow up history
Types of Data Sources - Answers - Primary Source: The patient
Secondary Source: Can be family members,
significant others, or medical records
*always establish reliability of the source
Taking a Health History - Answers - Provides a database about a patients past and
present health, and patients personal beliefs that influence health and illness.
Records subjective and essential data
