NUR 2092 Health Assessment Exam 1
Assessment - The collection of subjective and objective data about a patient's health
Subjective data - Information provided by the
affected individual
Objective data - Information obtained by the
health care provider through observation and inspecting,
percussing, palpating, and auscultating during the
physical examination
Database - Totality of information available
about the patient, including subjective data, objective data,
and the patient's medical record and laboratory studies
Purpose of an assessment - Make a judgement or diagnosis
Diagnostic reasoning - The process of analyzing health
data and drawing conclusions to identify diagnoses
Cues - Pieces of information, signs, symptoms, or laboratory data
Hypotheses - Tentative explanations for a cue or a set cues and can serve as a basis for further
investigation
, Steps of diagnostic reasoning - 1. Attending to available cues
2. Formulating hypothesis
3. Gathering data
4. Evaluating hypothesis
Steps of nursing process - 1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Novice nurse - Has no experience with specific patient populations and uses rules to guide performance
Proficient nurse - Understands a patient situation as a whole rather than as a list of tasks, attends to an
assessment data pattern, and acts without consciously labeling it
Expert nurse - Has an intuitive grasp of a clinical situation and zeroes in on the accurate solution
Critical thinking - The multidimensional thinking process needed for sound diagnostic reasoning and
clinical judgment
First-level priority problems - Emergent, life-threatening,
and immediate, such as establishing an airway or supporting breathing
Second-level priority problems - next in urgency; require prompt intervention to prevent deterioration,
and may include a mental status change or acute pain, or abnormal laboratory values
Third-level priority problems - Important to the patient's health but can be addressed after more urgent
health problems are addressed
Assessment - The collection of subjective and objective data about a patient's health
Subjective data - Information provided by the
affected individual
Objective data - Information obtained by the
health care provider through observation and inspecting,
percussing, palpating, and auscultating during the
physical examination
Database - Totality of information available
about the patient, including subjective data, objective data,
and the patient's medical record and laboratory studies
Purpose of an assessment - Make a judgement or diagnosis
Diagnostic reasoning - The process of analyzing health
data and drawing conclusions to identify diagnoses
Cues - Pieces of information, signs, symptoms, or laboratory data
Hypotheses - Tentative explanations for a cue or a set cues and can serve as a basis for further
investigation
, Steps of diagnostic reasoning - 1. Attending to available cues
2. Formulating hypothesis
3. Gathering data
4. Evaluating hypothesis
Steps of nursing process - 1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Novice nurse - Has no experience with specific patient populations and uses rules to guide performance
Proficient nurse - Understands a patient situation as a whole rather than as a list of tasks, attends to an
assessment data pattern, and acts without consciously labeling it
Expert nurse - Has an intuitive grasp of a clinical situation and zeroes in on the accurate solution
Critical thinking - The multidimensional thinking process needed for sound diagnostic reasoning and
clinical judgment
First-level priority problems - Emergent, life-threatening,
and immediate, such as establishing an airway or supporting breathing
Second-level priority problems - next in urgency; require prompt intervention to prevent deterioration,
and may include a mental status change or acute pain, or abnormal laboratory values
Third-level priority problems - Important to the patient's health but can be addressed after more urgent
health problems are addressed
