NUR2180 Module 3 Quiz Focused Review
• Subjective vs objective data
o Subjective
▪ Health history
o Objective
▪ Physical assessment
• Components of a health history
o Chief complaint
o Present health status
o Past health history
o Current lifestyle
o Psychosocial status
o Family history
o Review of symptoms
• Types of databases
o Complete total health database
▪ Includes complete health history and full physical examination
▪ Describes current and past health state and forms baseline to measure all
future changes
▪ Yields first diagnoses
o Episodic or problem-centered database
▪ For limited or short-term problems
▪ Collect “mini” database, smaller scope and more focused than complete
database.
▪ Concerns mainly one problem, one cue complex, or one body system
▪ History and examination follow direction of presenting concern
o Follow-up database (found in doctors office)
▪ Status of all identified problems should be evaluated at regular and
appropriate intervals
▪ Note changes that have occurred
▪ Evaluate whether problem is getting better or worse
▪ Identify coping strategies being used
o Emergency database (usually ER or Trauma)
▪ Rapid collections of data, often compiled concurrently with lifesaving
measures
▪ Diagnosis must be rapid and comprehensive in nature
• Therapeutic vs non-therapeutic communication
o Therapeutic
▪ Active listening
▪ Sharing observations
▪ Sharing empathy
▪ Sharing hope
, ▪ Sharing humor
▪ Sharing feelings
▪ Using touch
▪ Silence
▪ Providing Information
▪ Clarifying
▪ Focusing
▪ Paraphrasing
▪ Asking relevant questions
▪ Summarizing
▪ empathy
o Non-Therapeutic
▪ Asking personal questions
▪ Giving personal opinions
▪ Changing the subject
▪ Automatic responses
▪ False reassurance
▪ Self-Disclosure
▪ Confrontation
▪ Sympathy
▪ Asking for Explanations
▪ Approval or Disapproval
▪ Defensive Responses
▪ Passive or Aggressive Responses
▪ Arguing
• Characteristics of a culture
o Immigrants commonly maintain traditional eating customs long after language
and manner of dress of adopted country become routine
o Newly arriving immigrants may be at higher nutritional risk
▪ Often coming from countries with poor resources and nutrition related
problems
o Unfamiliar with foods, food preparation, food buying habits and food storage
o Standard tables for weight and height may not be appropriate
o Need to know food habits in regard to religion and culture
• Types of Nutritional assessments
o Anthropometric measurements
o Swallowing assessment prn
o Lab test
▪ Risk factors for a poor nutritional intake
▪ Questions re weight loss? Wt gain?
▪ How does age factor into nutritional intake?
▪ Food habits and customs
• Subjective vs objective data
o Subjective
▪ Health history
o Objective
▪ Physical assessment
• Components of a health history
o Chief complaint
o Present health status
o Past health history
o Current lifestyle
o Psychosocial status
o Family history
o Review of symptoms
• Types of databases
o Complete total health database
▪ Includes complete health history and full physical examination
▪ Describes current and past health state and forms baseline to measure all
future changes
▪ Yields first diagnoses
o Episodic or problem-centered database
▪ For limited or short-term problems
▪ Collect “mini” database, smaller scope and more focused than complete
database.
▪ Concerns mainly one problem, one cue complex, or one body system
▪ History and examination follow direction of presenting concern
o Follow-up database (found in doctors office)
▪ Status of all identified problems should be evaluated at regular and
appropriate intervals
▪ Note changes that have occurred
▪ Evaluate whether problem is getting better or worse
▪ Identify coping strategies being used
o Emergency database (usually ER or Trauma)
▪ Rapid collections of data, often compiled concurrently with lifesaving
measures
▪ Diagnosis must be rapid and comprehensive in nature
• Therapeutic vs non-therapeutic communication
o Therapeutic
▪ Active listening
▪ Sharing observations
▪ Sharing empathy
▪ Sharing hope
, ▪ Sharing humor
▪ Sharing feelings
▪ Using touch
▪ Silence
▪ Providing Information
▪ Clarifying
▪ Focusing
▪ Paraphrasing
▪ Asking relevant questions
▪ Summarizing
▪ empathy
o Non-Therapeutic
▪ Asking personal questions
▪ Giving personal opinions
▪ Changing the subject
▪ Automatic responses
▪ False reassurance
▪ Self-Disclosure
▪ Confrontation
▪ Sympathy
▪ Asking for Explanations
▪ Approval or Disapproval
▪ Defensive Responses
▪ Passive or Aggressive Responses
▪ Arguing
• Characteristics of a culture
o Immigrants commonly maintain traditional eating customs long after language
and manner of dress of adopted country become routine
o Newly arriving immigrants may be at higher nutritional risk
▪ Often coming from countries with poor resources and nutrition related
problems
o Unfamiliar with foods, food preparation, food buying habits and food storage
o Standard tables for weight and height may not be appropriate
o Need to know food habits in regard to religion and culture
• Types of Nutritional assessments
o Anthropometric measurements
o Swallowing assessment prn
o Lab test
▪ Risk factors for a poor nutritional intake
▪ Questions re weight loss? Wt gain?
▪ How does age factor into nutritional intake?
▪ Food habits and customs
