NR 302 Health Assessment
Study Guide Exam 1
Know the nursing process and be able to define and apply the terms (EX: Planning is the
process that occurs after the assessment data has been collected and interpreted, and a
nursing diagnosis has been formed)
A: Assessment
Assessment is the collection of subjective and objective data about a patient’s health.
Client Interview
Physical Examination
Obtaining a health history (including dietary data)
Family history/report
Diagnostic Data
Observation
• Subjective data consist of information provided by the affected individual.
• Objective data include information obtained by the health care provider through
observation and inspecting, percussing, palpating, and auscultating during the physical
examination.
D: Diagnosis (nursing)
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to
identify diagnoses. This process has four major components:
• Attending to initially available cues, which are pieces of information, signs, symptoms,
or laboratory data;
• Formulating diagnostic hypotheses, which are tentative explanations for a cue or a set
of cues and can serve as a basis for further investigation;
• Gathering data relative to the tentative hypotheses; and
, • Evaluating each hypothesis with the new data collected, which leads to a final
diagnosis.
P: Planning - Planning is the process of developing a plan and establishing SMART
goals in order to achieve a desired outcome such as reducing pain or improving
cardiovascular function.
I: Interventionsie something you do for the patient, like re-orienting them to their room each
time they go into it if they are confusedThe implementation phase of the process is the
actionable part of the process where the individual and medical team implement the
care plan, SMART goals and interventions so that the individual can achieve their
goals and the process can be evaluated and measured.
The implementation phase may be performed using a combination of direct care
and indirect care.
Direct care is care that is given directly to the patient in either a physical or
verbal manner.
Direct care may include assisting the patient with mobility, performing physical
care and range of motion exercises with the patient and assisting with daily
living activities.
It may also include coaching, counseling and providing feedback to the
individual.
Indirect care is care that is given while away from the patient.
Indirect care may include monitoring / supervising the medical staff, delegating
responsibilities and advocating on behalf of the individuals you care for.
E: Evaluation
This is the part where the medical professionals assess and evaluate the success of the
planning and implementation processes to ensure that the individual is making
progress towards his/her goals and is achieving the desired outcome.
Evaluate if the process is working and identify what is bringing the individual
closer to his/her goals.
Study Guide Exam 1
Know the nursing process and be able to define and apply the terms (EX: Planning is the
process that occurs after the assessment data has been collected and interpreted, and a
nursing diagnosis has been formed)
A: Assessment
Assessment is the collection of subjective and objective data about a patient’s health.
Client Interview
Physical Examination
Obtaining a health history (including dietary data)
Family history/report
Diagnostic Data
Observation
• Subjective data consist of information provided by the affected individual.
• Objective data include information obtained by the health care provider through
observation and inspecting, percussing, palpating, and auscultating during the physical
examination.
D: Diagnosis (nursing)
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to
identify diagnoses. This process has four major components:
• Attending to initially available cues, which are pieces of information, signs, symptoms,
or laboratory data;
• Formulating diagnostic hypotheses, which are tentative explanations for a cue or a set
of cues and can serve as a basis for further investigation;
• Gathering data relative to the tentative hypotheses; and
, • Evaluating each hypothesis with the new data collected, which leads to a final
diagnosis.
P: Planning - Planning is the process of developing a plan and establishing SMART
goals in order to achieve a desired outcome such as reducing pain or improving
cardiovascular function.
I: Interventionsie something you do for the patient, like re-orienting them to their room each
time they go into it if they are confusedThe implementation phase of the process is the
actionable part of the process where the individual and medical team implement the
care plan, SMART goals and interventions so that the individual can achieve their
goals and the process can be evaluated and measured.
The implementation phase may be performed using a combination of direct care
and indirect care.
Direct care is care that is given directly to the patient in either a physical or
verbal manner.
Direct care may include assisting the patient with mobility, performing physical
care and range of motion exercises with the patient and assisting with daily
living activities.
It may also include coaching, counseling and providing feedback to the
individual.
Indirect care is care that is given while away from the patient.
Indirect care may include monitoring / supervising the medical staff, delegating
responsibilities and advocating on behalf of the individuals you care for.
E: Evaluation
This is the part where the medical professionals assess and evaluate the success of the
planning and implementation processes to ensure that the individual is making
progress towards his/her goals and is achieving the desired outcome.
Evaluate if the process is working and identify what is bringing the individual
closer to his/her goals.
