NUR2092 Health Assessment Exam #1
Steps of the Nursing Process - ANSAssessment - gather data
Diagnosis - problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatment plan, intervention
Implementation - doing the plan
Evaluation - Was it successful, meet the goals
Define Subjective Data - ANSWhat patient says about himself or herself during history taking
symptoms
Define Objective Data - ANSObserved when inspecting, percussing, palpating, and
auscultating patient during physical examination
signs
Factors of Diagnosis - ANS-Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy
-Look for gaps in your information
-Interpret data and identify problems
-Document the diagnosis
Factors of Outcome Identification - ANS-Identify expected outcomes related to patient
individualization
-Ensure outcomes have the SMART components
-Specify short-term and long-term goal measurement criteria
What does SMART stand for? - ANSSpecific, Measurable, Attainable, Realistic, Timely
Factors of Planning - ANS-Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members for the
patient
-Document plan of care
Factors of Evaluation - ANS-Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome: does something need to be done
-If NOT reached: identify reasons for not achieving
-Modify plan if needed
-Document in plan of care
, Evidence-Based Decision Making factors - ANS-Best evidence from clinical review of
research literature
-The providers clinical expertise
-Patient's preference and values
-Physical examination and assessment of patient
Focused Database - ANSProblem-centered
Used for a limited or short-term problem
Smaller scope and more targeted than the complete database
Complete Database - ANSIncludes a complete health history and full physical examination
Yielding the first diagnosis
Steps in Priority Problem Levels - ANS1. First-level priority: emergent, life threatening,
immediate
2. Second- level: next in urgency, requires attention to prevent further deterioration
3. Third-Level: important to patient's health, but can be addressed after urgent problems
What are the two parts to Communicating? - ANS1. Sending
2. Receiving
In communication what are the two types in "sending"? - ANS1. Verbal: words/tone
2. Nonverbal: less conscious
In communication, what does "receiving" mean? - ANSInterpretation based on past
experiences, culture, and self concept
Physical and emotional state
Communication does what with a patient? - ANS-Builds a relationship
-Builds rapport
Key to Communication - ANSIs the receiver getting the message the way it was intended?
Active listening
Types of questions in Therapeutic Communication - ANSOpen-ended: narrative answers,
feelings and opinions, develops rapport
Close-ended: yes/no questions, used for specific information, limits rapport
In Therapeutic Communication, what are the types of responses focused on the client's
frame of reference? - ANSCLARIFICATION (rephrase)
FACILITATION (nodding, Hmm,hmm)
SILENCE (when to use)
SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I
understand")
Steps of the Nursing Process - ANSAssessment - gather data
Diagnosis - problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatment plan, intervention
Implementation - doing the plan
Evaluation - Was it successful, meet the goals
Define Subjective Data - ANSWhat patient says about himself or herself during history taking
symptoms
Define Objective Data - ANSObserved when inspecting, percussing, palpating, and
auscultating patient during physical examination
signs
Factors of Diagnosis - ANS-Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy
-Look for gaps in your information
-Interpret data and identify problems
-Document the diagnosis
Factors of Outcome Identification - ANS-Identify expected outcomes related to patient
individualization
-Ensure outcomes have the SMART components
-Specify short-term and long-term goal measurement criteria
What does SMART stand for? - ANSSpecific, Measurable, Attainable, Realistic, Timely
Factors of Planning - ANS-Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members for the
patient
-Document plan of care
Factors of Evaluation - ANS-Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome: does something need to be done
-If NOT reached: identify reasons for not achieving
-Modify plan if needed
-Document in plan of care
, Evidence-Based Decision Making factors - ANS-Best evidence from clinical review of
research literature
-The providers clinical expertise
-Patient's preference and values
-Physical examination and assessment of patient
Focused Database - ANSProblem-centered
Used for a limited or short-term problem
Smaller scope and more targeted than the complete database
Complete Database - ANSIncludes a complete health history and full physical examination
Yielding the first diagnosis
Steps in Priority Problem Levels - ANS1. First-level priority: emergent, life threatening,
immediate
2. Second- level: next in urgency, requires attention to prevent further deterioration
3. Third-Level: important to patient's health, but can be addressed after urgent problems
What are the two parts to Communicating? - ANS1. Sending
2. Receiving
In communication what are the two types in "sending"? - ANS1. Verbal: words/tone
2. Nonverbal: less conscious
In communication, what does "receiving" mean? - ANSInterpretation based on past
experiences, culture, and self concept
Physical and emotional state
Communication does what with a patient? - ANS-Builds a relationship
-Builds rapport
Key to Communication - ANSIs the receiver getting the message the way it was intended?
Active listening
Types of questions in Therapeutic Communication - ANSOpen-ended: narrative answers,
feelings and opinions, develops rapport
Close-ended: yes/no questions, used for specific information, limits rapport
In Therapeutic Communication, what are the types of responses focused on the client's
frame of reference? - ANSCLARIFICATION (rephrase)
FACILITATION (nodding, Hmm,hmm)
SILENCE (when to use)
SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I
understand")
