Health History Components - Answers Includes:
1: Demographic Information
2: Source of History
3: Chief Concern
4: History of Present Illness
5: Past Health History / Current Health Status
6: Family History
7: Psychosocial History
8. Health Promotion Behaviors
Physical Assessment Techniques (Order) - Answers 1. Inspection
2. Auscultation
3. Palpation
4. Percussion
(abdomen is the exception: inspect, auscultate, percuss then palpate)
Health Promotion Behaviors - Answers heath history component
- exercise/activity, diet, sun exposure, safety equipment, substance use, environmental exposure/home
environment, resources, stress, sleep patterns, coping measures
- awareness of risks for heart disease, cancer, diabetes, stroke
Light Palpation vs Deep Palpation - Answers Light Palpation: Less than 1 cm (0.4 inch)
Deep Palpation: 4 cm (1.6 inch) for abdominal organs / masses
General Survey - Answers A written summary of the impression of the client's overall health. The nurse
gathers this information from the first encounter with the client and continues to make observations
throughout the assessment process.
a) Physical appearance
b) Body structure
c) Mobility
, d) Behavior
e) Vital signs
Nursing Process Framework Order - Answers assessment, analysis/data collection, planning,
implementation, evaluation
Assessment/Data collection - Answers Involves the systematic collection of information about clients'
present health status to identify needs and additional data to collect based on findings.
Subjective Data - Answers What the client tells the nurse. Ex: "my shoulder is really sore."
Objective Data - Answers Data the nurse obtains through observation and examination. Ex: Client
grimaces when attempting to brush their hair with the left arm
Analysis/Data Collection - Answers Nurses use critical thinking skills to identify clients health statuses or
problems, interpret/monitor the collection database, reach an appropriate nursing judgement about
health status and provide nursing care
Planning - Answers Nurses must establish priorities and optimal outcomes of care they can readily
measure and evaluate.
Implementation - Answers Nurses base the care they provide on assessment data, analyses, and the
plan of care they developed in the previous steps of the nursing process.
Evaluation - Answers Nurses' evaluate clients responses to nursing interventions and form a clinical
judgement about the extent to which clients have met the goals and outcomes.
Sources of Data for Collection and Assessment - Answers Observation, interviews with clients and
families, medical history, comprehensive / focused physical assessment, etc.
Critical Thinking and the Nursing Process - Answers Assessment / Data Collection: Collect information
about a clients present health to identify needs and to identify additional data to collect based on
findings.
Critical Thinking Skills - Answers Observe
Use Correct Techniques for Collecting Data
Differentiate between irrelevant and relevant data
Organize, categorize and validate data
Interpret assessment data and draw conclusion
Identify clusters and cues
Recognize actual problems