NUR 155: Comprehensive Exam 1 Study
Guide on Nursing Process & Vital Signs
galen college of nursing
NUR 155: Exam 1 Study Guide
Unit 1: The Nursing Process, Health History, and Physical Assessment
The nursing process is a foundational framework used to provide patient-centered care. It
involves critical thinking, clinical reasoning, and judgment. The five phases of the nursing
process are:
1. Assessment – Collection of data through patient history, interviews, observation,
and physical exams. Data can be subjective (what the patient reports) or objective
(what the nurse observes or measures).
2. Diagnosis – A clinical judgment about the patient’s actual or potential health
conditions or needs. Nurses use NANDA-I approved diagnoses to identify problems
and guide care plans.
3. Planning – Prioritization of nursing diagnoses, setting measurable goals/outcomes,
and selecting interventions. Goals should be SMART (Specific, Measurable, Attainable,
Realistic, Time-bound).
4. Implementation – Performing nursing interventions to achieve the patient’s goals.
This includes direct care, education, coordination of care, and documentation.
5. Evaluation – Determining if patient goals were met and reassessing the plan of care if
needed.
Health History and Interview Process
A complete health history includes biographical data, chief complaint, past medical history,
family history, lifestyle factors, and review of systems. It is conducted in three phases:
- Orientation Phase: Introduce yourself, explain the purpose, and establish trust.
- Working Phase: Gather detailed health information through open-ended and closed-ended
questions.
- Termination Phase: Summarize information, validate accuracy, and explain next steps.
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, Physical Assessment Techniques
Physical assessments follow a head-to-toe approach using four main techniques:
- Inspection: Visual observation including posture, color, and behavior.
- Palpation: Using touch to detect temperature, texture, moisture, tenderness, and masses.
- Percussion: Tapping body parts to determine density and detect abnormalities.
Downloaded by patrick kaylian ()
Guide on Nursing Process & Vital Signs
galen college of nursing
NUR 155: Exam 1 Study Guide
Unit 1: The Nursing Process, Health History, and Physical Assessment
The nursing process is a foundational framework used to provide patient-centered care. It
involves critical thinking, clinical reasoning, and judgment. The five phases of the nursing
process are:
1. Assessment – Collection of data through patient history, interviews, observation,
and physical exams. Data can be subjective (what the patient reports) or objective
(what the nurse observes or measures).
2. Diagnosis – A clinical judgment about the patient’s actual or potential health
conditions or needs. Nurses use NANDA-I approved diagnoses to identify problems
and guide care plans.
3. Planning – Prioritization of nursing diagnoses, setting measurable goals/outcomes,
and selecting interventions. Goals should be SMART (Specific, Measurable, Attainable,
Realistic, Time-bound).
4. Implementation – Performing nursing interventions to achieve the patient’s goals.
This includes direct care, education, coordination of care, and documentation.
5. Evaluation – Determining if patient goals were met and reassessing the plan of care if
needed.
Health History and Interview Process
A complete health history includes biographical data, chief complaint, past medical history,
family history, lifestyle factors, and review of systems. It is conducted in three phases:
- Orientation Phase: Introduce yourself, explain the purpose, and establish trust.
- Working Phase: Gather detailed health information through open-ended and closed-ended
questions.
- Termination Phase: Summarize information, validate accuracy, and explain next steps.
Downloaded by patrick kaylian ()
, Physical Assessment Techniques
Physical assessments follow a head-to-toe approach using four main techniques:
- Inspection: Visual observation including posture, color, and behavior.
- Palpation: Using touch to detect temperature, texture, moisture, tenderness, and masses.
- Percussion: Tapping body parts to determine density and detect abnormalities.
Downloaded by patrick kaylian ()
