NUR2092: Health Assessment Final Exam Review
Evidence Based Practice: a systematic approach emphasizing the best research evidence, the
clinician's experience, patient preferences and values, physical examination, and assessment to
make decisions about care
- clinical decision-making that integrates the best available research with clinical expertise
and patient characteristics and preferences
Health History:
1. Biographic data: name, address, phone #, DOB, age, gender, occupation
2. Reason for seeking care: the patient’s chief complaint (signs and symptoms)
3. Present Health or History of Present Illness: how the pt feels right now
4. Past Health: past health of the pt could have residual effects on current health state
(childhood illness/surgeries/injuries/operations)
5. Medication reconciliation: complete list of medications (OTC+ herbs) (name, dose,
schedule, often, side effects)
6. Family History: highlight diseases+ conditions for which the it can be at high risk
(genogram)
7. Review of Systems: evaluate the past + present health state of each body part (asking)
8. Functional Assessment ADL’s: measures ones self-care ability to care for themselves.
- Source of history:
o Pt: primary- Patient herself, who seems reliable
o Son or daughter: secondary- Patients son, John Ramirez, who seems reliable
- Reason for seeking care- Chief Complaint “Chest pains for 2 hours”
o History of Present Illness: HPI
▪ Location
▪ Quality
▪ Severity
▪ Timing
▪ Setting
▪ Aggravating or Relieving factors
▪ Associated Factors
▪ Patients Perspective
Pain Assessment: the 5th vital sign, is subjective data (collect the HPI)
- Visceral pain (organ)
- Somatic pain (muscular/skeletal)
- Referred (pain where pain is not)
o Acute pain: come and go (guarding, moaning/yelling, vital sign change)
o Chronic pain: longer than 6 months of pain (change in app, holding self-up bc of
bad back)
- Nociceptive pain: develops when functioning and intact nerve fibers in the periphery and
the CNS are stimulated. It is triggered by events outside the nervous system from actual
or potential tissue damage. Nociception can be divided into four phases: (1) transduction,
(2) transmission, (3) perception, and (4) modulation
- Pain scales for pts who are nonverbal or speak a different language
, Vital Signs:
o Temperature: oral, rectal (most accurate), tympanic (ear), temporal, axillary
o Pulse: Tachycardia: >100 normal response to stress, Bradycardia: <60, Normal:
60- 100
▪ 0 = absent 1+ = weak 2+ = normal 3+ = increased Bounding (heart is
pounding or racing)
o Respirations: Inspiration/Expiration
o B/P/systolic/diastolic: Hypertension: 180-209/110-119
o O2 Sat: 90-100, 98 and above is good (on finger)
o Pain
Nursing Process:
1) Assessment- collect data: exam, health history
2) Diagnosis: compare normal versus abnormal
3) Outcome Identification: expected outcome individualized to person
4) Planning: develop outcomes, interventions
5) Implementation: research, teaching + health promotion
6) Evaluation: plan, progress toward outcomes
Culture: shared attitudes, beliefs, roles, norms and values that occur among those who speak a
particular language or live in a geographic location
Religion: organized system of beliefs concerning the cause, nature and purpose of the universe,
belief in a divine or superhuman power to be obeyed + worshipped as creators + rulers of the
universe (whole, together)
Spirituality: born out of each persons unique life experience, his/her personal effect to find
purpose + meaning in life (more individual) (tree hugger)
Communication Techniques: asking open ended questions, closed or direct, silence,
clarification (understanding), repeating
General Survey: study of the whole person, begins with the 1st moment of encounter, helps to
form a global impression of the person (behavior, physical appearance, body structure, mobility)(
wt/ht w/in normal range (BMI),body parts equal bilat, stands erect, gait coordinated, maintains
eye contact, appropriate expressions, comfortable, cooperative, speech clear)
Purpose of Health Assessment: plan of care that identifies the specific needs of a client + how
they need to b addressed. Gathering info about the health status of the pt, analyzing +
synthesizing that data, making judgements about nursing interventions based on the findings +
evaluating pt care outcomes
Objective data: info gathered by healthcare team, factual + descriptive (SIGNS)
Subjective data: what the pt says about him/her (SYMPTOMS)
Evidence Based Practice: a systematic approach emphasizing the best research evidence, the
clinician's experience, patient preferences and values, physical examination, and assessment to
make decisions about care
- clinical decision-making that integrates the best available research with clinical expertise
and patient characteristics and preferences
Health History:
1. Biographic data: name, address, phone #, DOB, age, gender, occupation
2. Reason for seeking care: the patient’s chief complaint (signs and symptoms)
3. Present Health or History of Present Illness: how the pt feels right now
4. Past Health: past health of the pt could have residual effects on current health state
(childhood illness/surgeries/injuries/operations)
5. Medication reconciliation: complete list of medications (OTC+ herbs) (name, dose,
schedule, often, side effects)
6. Family History: highlight diseases+ conditions for which the it can be at high risk
(genogram)
7. Review of Systems: evaluate the past + present health state of each body part (asking)
8. Functional Assessment ADL’s: measures ones self-care ability to care for themselves.
- Source of history:
o Pt: primary- Patient herself, who seems reliable
o Son or daughter: secondary- Patients son, John Ramirez, who seems reliable
- Reason for seeking care- Chief Complaint “Chest pains for 2 hours”
o History of Present Illness: HPI
▪ Location
▪ Quality
▪ Severity
▪ Timing
▪ Setting
▪ Aggravating or Relieving factors
▪ Associated Factors
▪ Patients Perspective
Pain Assessment: the 5th vital sign, is subjective data (collect the HPI)
- Visceral pain (organ)
- Somatic pain (muscular/skeletal)
- Referred (pain where pain is not)
o Acute pain: come and go (guarding, moaning/yelling, vital sign change)
o Chronic pain: longer than 6 months of pain (change in app, holding self-up bc of
bad back)
- Nociceptive pain: develops when functioning and intact nerve fibers in the periphery and
the CNS are stimulated. It is triggered by events outside the nervous system from actual
or potential tissue damage. Nociception can be divided into four phases: (1) transduction,
(2) transmission, (3) perception, and (4) modulation
- Pain scales for pts who are nonverbal or speak a different language
, Vital Signs:
o Temperature: oral, rectal (most accurate), tympanic (ear), temporal, axillary
o Pulse: Tachycardia: >100 normal response to stress, Bradycardia: <60, Normal:
60- 100
▪ 0 = absent 1+ = weak 2+ = normal 3+ = increased Bounding (heart is
pounding or racing)
o Respirations: Inspiration/Expiration
o B/P/systolic/diastolic: Hypertension: 180-209/110-119
o O2 Sat: 90-100, 98 and above is good (on finger)
o Pain
Nursing Process:
1) Assessment- collect data: exam, health history
2) Diagnosis: compare normal versus abnormal
3) Outcome Identification: expected outcome individualized to person
4) Planning: develop outcomes, interventions
5) Implementation: research, teaching + health promotion
6) Evaluation: plan, progress toward outcomes
Culture: shared attitudes, beliefs, roles, norms and values that occur among those who speak a
particular language or live in a geographic location
Religion: organized system of beliefs concerning the cause, nature and purpose of the universe,
belief in a divine or superhuman power to be obeyed + worshipped as creators + rulers of the
universe (whole, together)
Spirituality: born out of each persons unique life experience, his/her personal effect to find
purpose + meaning in life (more individual) (tree hugger)
Communication Techniques: asking open ended questions, closed or direct, silence,
clarification (understanding), repeating
General Survey: study of the whole person, begins with the 1st moment of encounter, helps to
form a global impression of the person (behavior, physical appearance, body structure, mobility)(
wt/ht w/in normal range (BMI),body parts equal bilat, stands erect, gait coordinated, maintains
eye contact, appropriate expressions, comfortable, cooperative, speech clear)
Purpose of Health Assessment: plan of care that identifies the specific needs of a client + how
they need to b addressed. Gathering info about the health status of the pt, analyzing +
synthesizing that data, making judgements about nursing interventions based on the findings +
evaluating pt care outcomes
Objective data: info gathered by healthcare team, factual + descriptive (SIGNS)
Subjective data: what the pt says about him/her (SYMPTOMS)
