NUR2092 Health Assessment Exam 1 Study Guide
▪ Subjective data – Symptoms
➢ What the person says
▪ Objective data – Sign
➢ What the health professional find by
▪ Inspecting
▪ Palpation
▪ Percussion
▪ Auscultation
▪ Diagnostic Reasoning
➢ Attend to initially available cues
▪ Piece of information, sign, symptom, laboratory data
➢ Formulate Diagnostic hypotheses
▪ Tentative explanation for cues used as a basis for further investigation
➢ Gather data relative to tentative hypotheses
➢ Evaluate each hypothesis with new data collected to arrive at final diagnosis
▪ Critical Thinking Skills
➢ Identifying assumptions
▪ Recognize information taken for granted or fact without evidence for it
➢ Organized approach
▪ Use an organized, systematic assessment format
➢ Validation
▪ Check and corroborate accuracy and reliability of data
➢ Normal and abnormal
▪ Distinguish when identifying signs and symptoms
➢ Inferences of drawing valid conclusions
▪ Interpreting data and deriving correct conclusions
➢ Clustering related cues
▪ Assists seeing relationships among data
➢ Relevance
▪ Look at clusters of data and consider which are important for health problem
➢ Inconsistencies
▪ Recognize subjective data at odds with objective data
➢ Identify pattern
▪ Helps to see whole picture and discover missing of information
➢ Missing information
▪ Identify gaps in data or need for more specific interviewing or laboratory data to make diagnosis
➢ Health promotion
▪ Identify and manage known risk factors for individual age group and cultural status
➢ Risk diagnosis
➢ Setting priorities
• First-level problems – emergent, life threatening and immediate
◆ Airway – Breathing – Circulation/Cardiac – Vital signs (ABC’s plus V)
• Second-level priorities – prompt intervention to forestall further deterioration
◆ Mental status change, acute pain, acute urinary elimination, untreated medical problems, abnormal
laboratory values, risks of infection, risk to safety or security
• Third-level priority - those that are important to the patients health but can be addressed after more
urgent health problems are addressed
, ◆ Long term chronic problems
◆ Treatment is expected to take more time
• Collaborative problems – multiple disciplines
◆ Physiologic conditions in which nurses have the primary responsibility to diagnose the onset and
monitor the changes in status
➢ Collaborative problems
➢ Outcomes
▪ Specific, measurable, results expected to improve patients problem after treatment, timeframe
➢ Interventions
▪ Will interventions achieve expected outcomes
➢ Evaluation and corrective thinking
▪ Analyze outcomes and apply them for evaluation
➢ Comprehensive plan of care
▪ Evaluate and update plan
▪ Record and revise plan of care
➢ Nursing Process
▪ Assessment
• Collection of data
➢ Complete total health data base
▪ Complete health history and full physical
▪ Current and past health history forms a baseline to all future changes
▪ Yields first diagnosis
➢ Episodic or problem centered data base
▪ Short term problems
▪ Mini data base
▪ 1 problem, 1 cue, 1 body system
▪ Acute or chronic onset
➢ Follow-up data base
▪ Changes that occurred – better or worse?
▪ Coping strategies being used
➢ Emergency data base
▪ Rapid collection of data, often with lifesaving measures
▪ Diagnosis must be swift and sure
• Review clinical record
• Interview
➢ Establish rapport, build therapeutic relationship
➢ Teach person about health state and health promotion and prevention
▪ Contract terms – mutual goal for optimal health
• Time and place
• Introduction
• Purpose of the interview
• How long it will take
• Expectation for participation
• Presence of others
• Confidentiality
• Any cost that the patient must pay
◆
• Health history
➢ Biographical data
▪ Name
▪ Subjective data – Symptoms
➢ What the person says
▪ Objective data – Sign
➢ What the health professional find by
▪ Inspecting
▪ Palpation
▪ Percussion
▪ Auscultation
▪ Diagnostic Reasoning
➢ Attend to initially available cues
▪ Piece of information, sign, symptom, laboratory data
➢ Formulate Diagnostic hypotheses
▪ Tentative explanation for cues used as a basis for further investigation
➢ Gather data relative to tentative hypotheses
➢ Evaluate each hypothesis with new data collected to arrive at final diagnosis
▪ Critical Thinking Skills
➢ Identifying assumptions
▪ Recognize information taken for granted or fact without evidence for it
➢ Organized approach
▪ Use an organized, systematic assessment format
➢ Validation
▪ Check and corroborate accuracy and reliability of data
➢ Normal and abnormal
▪ Distinguish when identifying signs and symptoms
➢ Inferences of drawing valid conclusions
▪ Interpreting data and deriving correct conclusions
➢ Clustering related cues
▪ Assists seeing relationships among data
➢ Relevance
▪ Look at clusters of data and consider which are important for health problem
➢ Inconsistencies
▪ Recognize subjective data at odds with objective data
➢ Identify pattern
▪ Helps to see whole picture and discover missing of information
➢ Missing information
▪ Identify gaps in data or need for more specific interviewing or laboratory data to make diagnosis
➢ Health promotion
▪ Identify and manage known risk factors for individual age group and cultural status
➢ Risk diagnosis
➢ Setting priorities
• First-level problems – emergent, life threatening and immediate
◆ Airway – Breathing – Circulation/Cardiac – Vital signs (ABC’s plus V)
• Second-level priorities – prompt intervention to forestall further deterioration
◆ Mental status change, acute pain, acute urinary elimination, untreated medical problems, abnormal
laboratory values, risks of infection, risk to safety or security
• Third-level priority - those that are important to the patients health but can be addressed after more
urgent health problems are addressed
, ◆ Long term chronic problems
◆ Treatment is expected to take more time
• Collaborative problems – multiple disciplines
◆ Physiologic conditions in which nurses have the primary responsibility to diagnose the onset and
monitor the changes in status
➢ Collaborative problems
➢ Outcomes
▪ Specific, measurable, results expected to improve patients problem after treatment, timeframe
➢ Interventions
▪ Will interventions achieve expected outcomes
➢ Evaluation and corrective thinking
▪ Analyze outcomes and apply them for evaluation
➢ Comprehensive plan of care
▪ Evaluate and update plan
▪ Record and revise plan of care
➢ Nursing Process
▪ Assessment
• Collection of data
➢ Complete total health data base
▪ Complete health history and full physical
▪ Current and past health history forms a baseline to all future changes
▪ Yields first diagnosis
➢ Episodic or problem centered data base
▪ Short term problems
▪ Mini data base
▪ 1 problem, 1 cue, 1 body system
▪ Acute or chronic onset
➢ Follow-up data base
▪ Changes that occurred – better or worse?
▪ Coping strategies being used
➢ Emergency data base
▪ Rapid collection of data, often with lifesaving measures
▪ Diagnosis must be swift and sure
• Review clinical record
• Interview
➢ Establish rapport, build therapeutic relationship
➢ Teach person about health state and health promotion and prevention
▪ Contract terms – mutual goal for optimal health
• Time and place
• Introduction
• Purpose of the interview
• How long it will take
• Expectation for participation
• Presence of others
• Confidentiality
• Any cost that the patient must pay
◆
• Health history
➢ Biographical data
▪ Name
