FINAL EXAM STUDY GUIDE
THE NURSING PROCESS
Understand all steps in nursing process and be able to apply to all
systems listed below in the system sections
a. Assessment
Assessing the patient for subjective and objective data
b. Diagnoses
Nursing diagnosis based upon patient assessment
c. Planning
Plan for how to care for the patient based upon the nursing
diagnosis
d. Implementation
Implementing the patient’s care plan
e. Evaluation
Monitor patient to see if implementation is effective or
ineffective
Be able to format nursing. Diagnosis, goals, interventions correctly
PES: problem, etiology, symptoms
Ex: Activity intolerance related to imbalance between
oxygen supply and demand as evidence by verbal report of
fatigue, abnormal heart rate in response to activity,
difficulty breathing
Apply the nursing process by priority
ABCDE
A: airway
B: breathing
C: circulation
D: disability
E: exposure
Critical thinking / Clinical Reasoning
Critical thinking: NOT trial and error
Application of knowledge
Experience to identify the patient problems
Critical reasoning: develops over time make decisions
Uses critical thinking, knowledge, and experience to develop
solutions to problems and make decisions in a clinical setting
Skills that depend on critical thinking:
Problem solving (interchangeable)
o Systematic, analytic approach to finding a solution to a problem
Decision making
1
, o Choosing a solution or answer from among different options;
often considered a step in the problem-solving process
Reasoning
o Logical thinking that links thoughts, ideas, and facts together in a
meaningful way; used in scientific inquiry and problem-solving
Judgement
o The results or decision related to the processes of thinking and
reasoning
Essentials of Health Assessment
1. History - subjective data
i. Patient interview
ii. Family members if patient is unable to speak for self
iii. Other health care provider notes
2. Physical examination - objective data
i. Physical exam
ii. Patient appearance
iii. Patient sounds, feelings, etc.
3. Documentation of data
i. Documented in a systematic way and shared with other
members of the healthcare team
ii. Symptoms, signs, clinical manifestations
4. Building Health History
a. Understand the importance of the health history
Understanding patient past and risk factors
Any prior health problems or acute/chronic illnesses
Ability to provide the best care to patient based upon
knowing the most we can about a patient
b. Components of health History
Subjective and objective data
Past medical history
Social and psychosocial history
Allergies
Immunizations
Surgeries or injuries
Childbirth
Nutrition and physical activity
Access to care
Use of alcohol or drugs
c. Type of data – Objective, Subjective, Primary, Secondary
Primary data: comes from the patient themselves
Secondary data: comes from family members or other
providers, caretakers, etc. if patient is unable to tell it
themselves
d. Data Collection
a. Signs
2
THE NURSING PROCESS
Understand all steps in nursing process and be able to apply to all
systems listed below in the system sections
a. Assessment
Assessing the patient for subjective and objective data
b. Diagnoses
Nursing diagnosis based upon patient assessment
c. Planning
Plan for how to care for the patient based upon the nursing
diagnosis
d. Implementation
Implementing the patient’s care plan
e. Evaluation
Monitor patient to see if implementation is effective or
ineffective
Be able to format nursing. Diagnosis, goals, interventions correctly
PES: problem, etiology, symptoms
Ex: Activity intolerance related to imbalance between
oxygen supply and demand as evidence by verbal report of
fatigue, abnormal heart rate in response to activity,
difficulty breathing
Apply the nursing process by priority
ABCDE
A: airway
B: breathing
C: circulation
D: disability
E: exposure
Critical thinking / Clinical Reasoning
Critical thinking: NOT trial and error
Application of knowledge
Experience to identify the patient problems
Critical reasoning: develops over time make decisions
Uses critical thinking, knowledge, and experience to develop
solutions to problems and make decisions in a clinical setting
Skills that depend on critical thinking:
Problem solving (interchangeable)
o Systematic, analytic approach to finding a solution to a problem
Decision making
1
, o Choosing a solution or answer from among different options;
often considered a step in the problem-solving process
Reasoning
o Logical thinking that links thoughts, ideas, and facts together in a
meaningful way; used in scientific inquiry and problem-solving
Judgement
o The results or decision related to the processes of thinking and
reasoning
Essentials of Health Assessment
1. History - subjective data
i. Patient interview
ii. Family members if patient is unable to speak for self
iii. Other health care provider notes
2. Physical examination - objective data
i. Physical exam
ii. Patient appearance
iii. Patient sounds, feelings, etc.
3. Documentation of data
i. Documented in a systematic way and shared with other
members of the healthcare team
ii. Symptoms, signs, clinical manifestations
4. Building Health History
a. Understand the importance of the health history
Understanding patient past and risk factors
Any prior health problems or acute/chronic illnesses
Ability to provide the best care to patient based upon
knowing the most we can about a patient
b. Components of health History
Subjective and objective data
Past medical history
Social and psychosocial history
Allergies
Immunizations
Surgeries or injuries
Childbirth
Nutrition and physical activity
Access to care
Use of alcohol or drugs
c. Type of data – Objective, Subjective, Primary, Secondary
Primary data: comes from the patient themselves
Secondary data: comes from family members or other
providers, caretakers, etc. if patient is unable to tell it
themselves
d. Data Collection
a. Signs
2
