NUR 2092 HEALTH ASSESSMENT EXAM 1 STUDY GUIDE VERSION 1
1. Subjective vs. Objective Data: Subjective Data is the information that a patient says
about self. Objective data is what the health professional observes by inspecting,
percussing, palpating and auscultating during physical examination.
2. Diagnostic Reasoning: is the process of analyzing health data and drawing conclusions
to identify diagnoses. Hypothetico-deductive process has 4 components: (1) attending
to initially available cues (2) formulating a diagnostic hypothesis (3) gathering data
relative to the tentative hypotheses (4) evaluating each hypothesis with the new data
collected, thus arriving at a final diagnosis. Cue: a piece of info, a sign or symptom, or a
piece of laboratory data. Hypothesis: a tentative explanation for a cue or a set of cues
that can be used as a basis for further investigation.
3. Critical Thinking Skills: Critical thinking is the means by which we learn to assess and
modify before acting. Critical thinking is required for sound diagnostic reasoning and
clinical judgment. Critical thinking is a multi-dimensional thinking process, not a linear
approach to problem solving. Approach problems in a nonjudgmental way and avoid
making assumptions. Primary cause of misdiagnosis is the clinician’s bias. Cluster items
that are related. Final step to critical thinking includes evaluation and planning.
4. Priority Levels of Care:
o First Level Priority Problems: those that are emergent, life threatening, and
immediate, such as establishing an airway or supporting breathing: (ABC’s and V:
Airway, Breathing Problems, Cardia/Circulation problems, Vital Sign Concerns
(high fever…) Exceptions: CPR, do this immediately
o Second Level Priority Problems: those that are next in urgency- those requiring
your prompt intervention to forestall further deterioration
Mental status change (confusion, decreased alertness…)
Untreated medical problems requiring immediate attention (person
with diabetes who has not had insulin..)
Acute Pain
Acute urinary elimination problems
Abnormal lab values
Risks of infection, safety, or security (for patient or others)
o Third Level Priority Problems: those that are important to the patient’s health but
can be addressed after more urgent health problems are addressed.
Interventions to treat these problems are more long term, and the response to
treatment is expected to take more time. (Problems with lack of knowledge,
activity, rest, family coping…)
o Collaborative Problems: these involves multiple disciplines for treatment. These
are certain physiologic conditions that the nurses have primary responsibility to
diagnose the onset and monitor the changes is status. (Data regarding diabetes;
with this the sudden imbalance of insulin and blood sugar has profound
, implications on the central nervous and GI systems. Patient’s care will be
monitored by nurses, doctors, dieticians, and case managers.)
5. Evidence Based Practice (EBP): is the integration of clinical expertise, patient values
and the best research evidence into the decision making process for patient care.
6. Nursing Process: the standards practice of nursing; problem-solving approach
o Assessment: collection of data about person’s health state.
Collect Data: Review of the clinical record, health history, physical
examination, functional assessment, risk assessment, review of literature
Use evidence-based assessment techniques
Document relevant data.
Nursing Process Con’t:
o Diagnosis:
Compare clinical findings with normal and abnormal and developmental
needs
Interpret data:
Identify clusters of clues
Make hypothesis
Test hypothesis
Derive diagnosis
Validate Diagnosis
Document Diagnosis
o Outcome Identification:
Identify expected outcomes
Individualize to the person
Culturally appropriate
Realistic and measurable
Include a timeline
o Planning:
Establish Priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
Document Plan of Care
o Implementation:
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
1. Subjective vs. Objective Data: Subjective Data is the information that a patient says
about self. Objective data is what the health professional observes by inspecting,
percussing, palpating and auscultating during physical examination.
2. Diagnostic Reasoning: is the process of analyzing health data and drawing conclusions
to identify diagnoses. Hypothetico-deductive process has 4 components: (1) attending
to initially available cues (2) formulating a diagnostic hypothesis (3) gathering data
relative to the tentative hypotheses (4) evaluating each hypothesis with the new data
collected, thus arriving at a final diagnosis. Cue: a piece of info, a sign or symptom, or a
piece of laboratory data. Hypothesis: a tentative explanation for a cue or a set of cues
that can be used as a basis for further investigation.
3. Critical Thinking Skills: Critical thinking is the means by which we learn to assess and
modify before acting. Critical thinking is required for sound diagnostic reasoning and
clinical judgment. Critical thinking is a multi-dimensional thinking process, not a linear
approach to problem solving. Approach problems in a nonjudgmental way and avoid
making assumptions. Primary cause of misdiagnosis is the clinician’s bias. Cluster items
that are related. Final step to critical thinking includes evaluation and planning.
4. Priority Levels of Care:
o First Level Priority Problems: those that are emergent, life threatening, and
immediate, such as establishing an airway or supporting breathing: (ABC’s and V:
Airway, Breathing Problems, Cardia/Circulation problems, Vital Sign Concerns
(high fever…) Exceptions: CPR, do this immediately
o Second Level Priority Problems: those that are next in urgency- those requiring
your prompt intervention to forestall further deterioration
Mental status change (confusion, decreased alertness…)
Untreated medical problems requiring immediate attention (person
with diabetes who has not had insulin..)
Acute Pain
Acute urinary elimination problems
Abnormal lab values
Risks of infection, safety, or security (for patient or others)
o Third Level Priority Problems: those that are important to the patient’s health but
can be addressed after more urgent health problems are addressed.
Interventions to treat these problems are more long term, and the response to
treatment is expected to take more time. (Problems with lack of knowledge,
activity, rest, family coping…)
o Collaborative Problems: these involves multiple disciplines for treatment. These
are certain physiologic conditions that the nurses have primary responsibility to
diagnose the onset and monitor the changes is status. (Data regarding diabetes;
with this the sudden imbalance of insulin and blood sugar has profound
, implications on the central nervous and GI systems. Patient’s care will be
monitored by nurses, doctors, dieticians, and case managers.)
5. Evidence Based Practice (EBP): is the integration of clinical expertise, patient values
and the best research evidence into the decision making process for patient care.
6. Nursing Process: the standards practice of nursing; problem-solving approach
o Assessment: collection of data about person’s health state.
Collect Data: Review of the clinical record, health history, physical
examination, functional assessment, risk assessment, review of literature
Use evidence-based assessment techniques
Document relevant data.
Nursing Process Con’t:
o Diagnosis:
Compare clinical findings with normal and abnormal and developmental
needs
Interpret data:
Identify clusters of clues
Make hypothesis
Test hypothesis
Derive diagnosis
Validate Diagnosis
Document Diagnosis
o Outcome Identification:
Identify expected outcomes
Individualize to the person
Culturally appropriate
Realistic and measurable
Include a timeline
o Planning:
Establish Priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
Document Plan of Care
o Implementation:
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
