NR 302 HEALTH ASS Exam 1 Latest updated ,100% CORRECT
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Course
NR 302
Institution
NR 302
NR 302 HEALTH ASS Exam 1 Latest updated
Exam 1 Concepts
Chapter 1: Evidence-Based Assessment
• Define and recognize examples of Subjective and Objective data
o Objective is obtained through observation and is verifiable; information gathered from the patient by the use of observation, pal...
Exam 1 Concepts
Chapter 1: Evidence-Based Assessment
• Define and recognize examples of Subjective and Objective data
o Objective is obtained through observation and is verifiable;
information gathered from the patient by the use of observation,
palpation, percussion, and auscultation, as well as the use of
instruments and techniques that provide specific measurements
o Subjective is information that the patient shares about his or her
health situation. They are gathered through the patients report and are
verifiable only by the patient.
• Identify order and tasks of each step of the Nursing Process
o ADPIE
o Assessment- information collection/ gathering data
o Diagnosis- information interpretation, stating problems & strengths
o Plan/ Outcome- setting nursing goals desired outcomes
and planning interventions
o Implementation- performing nursing interventions
o Evaluation- patient’s status and effectiveness of nursing interventions
• Recognize the difference between different levels of Nursing Experience
o Novice: starting out in an area of learning; uses rules to guide
performance
o Competency: building on 2 to 3 years of clinical experience; see
actions in the context of patient goals or plans
o Proficient: adding to time and experience; understands the patient
situation as a whole rather than individual parts-apply long term
goals
o Expert: attained mastery of an area of learning; performs clinical
judgement using intuitive analysis
• Define and identify examples of Levels of Priority: 1st, 2nd, and 3rd levels
o 1st level: emergent, life threatening, and immediate; like airway,
breathing, and circulation
o 2nd level: next in urgency, requiring attention so as to avoid further
deterioration; mental status changes, acute pain, infection risk,
abnormal laboratory values, and elimination problems
o 3rd level: important to patient’s health but can be addressed after
more urgent problems are addressed; like lack of knowledge,
, mobility problems, and family coping
o Collaborative problems: approach to treatment involves multiple
disciplines
• Define the Four Types of Databases: Complete, Focused, Follow-Up, and
Emergency
o Complete total health database describes current and past health
state and forms baselines to measure all future changes; complete
physical examination; yields first diagnosis
, o Focused or problem-centered database: collect “mini” database,
smaller scope and more focused than complete database; short term
problem
o Follow-up database: status of all identified problems should be
evaluated at regular and appropriate intervals; follows up with both
short- term and chronic health problems; What change has
occurred? Is the problem getting better or worse?
o Emergency database: rapid collection of data often complied
concurrently with lifesaving measure; diagnosis must be swift and
sure
Chapter 4: The Complete Health History
• Identify components and purpose for
o Collect subjective data to combine with objective data from
physical exam and lab studies to from the database
o Provides a complete picture of patients past and present health status
o Can be used as a screening tool for detection of abnormalities
o Printed or electronic format that is available for review, validation, and
updates
o Sequence may vary in terms of obtained information
o Those in primary care settings may use all of it, whereas those in a
hospital may focus primarily on the history of present illness and the
functional, or patterns of living, data.
HEALTH HISTORY SEQUENCE
o Biographic data:
▪ Name, address, and phone number
▪ Age, birth date, and birthplace
▪ Gender (identification) and relationship status
▪ Race and ethnic origin
▪ Occupation: usual and present
▪ Primary language
o Source of history:
▪ Record who furnished information, usually the person,
although source may be relative or friend
▪ Judge reliability of informant and how willing he or she is to
communicate
• Reliability leads to consistency of information
▪ Note any special circumstances, such as use of interpreter
• Identify how to perform a Review of Systems
o Evaluate past and present state of each body system
▪ Assess that all pertinent data relative to each body system have
been noted
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