NURS 328 - Final Exam Study Guide
order of total body assessment by systems - general health state
- nutrition and hydration
- skin, hair, nails
- head and neck
- eyes, ears, nose, mouth, and throat
- thorax and lungs
- heart, neck vessels, peripheral vascular
- breasts
- abdominal → gastrointestinal
- abdominal → urinary
- musculoskeletal
- neurological
- genitalia
- anus, rectum, and prostate
- endocrine and hematologic systems
considerations for the interview environment - limit distractions
- avoid using technical language
- avoid interrupting the patient
,NURS 328 - Final Exam Study Guide
phases of the interview process 1. pre-interaction phase
- compiling existing data
- preparing for patient interview from existing medical records
- looking at the patient's chart
2. beginning phase
- introduction
- state the purpose of the interview
3. working phase
- closed ended or direct questions for specific info
- open ended questions, broad answers in patient's words
- avoid "why" questions
4. closing phase
- summarizing
- stating the most important 2-3 problems or patterns
,NURS 328 - Final Exam Study Guide
emergency/life-threatening assessment - based on the mnemonic ABCDE
- A → airway
- B → breathing
- C → circulation
- D → disability
- E → exposure
comprehensive assessment - complete health history and physical assessment performed
- annually for outpatients
- upon hospital/long-term care admission
focused assessment - occurs in all settings
- smaller in scope but increased depth for specific issues
first-level priority patient - emergency, life-threatening, and immediate
- example → ABCs, bleeding out
second-level priority patient - requiring attention to avoid further deterioration
- example → sepsis, hypoglycemia
third-level priority patient - important to the patient's health but can be addressed after more urgent
problems are addressed
- example → UTIs, fracture
, NURS 328 - Final Exam Study Guide
allergy questions - verify allergies with patients and compare them to the allergies in their
chart
- note the type of response to the allergy → rash, throat swelling, difficulty
breathing, anaphylactic shock
- differentiate between an adverse reaction (nauseousness) and an allergic
reaction (throat swelling, difficulty breathing)
documentation of allergies - patient should have a name band applied noting the allergy
- allergies should be documented appropriately in the patient's chart
acute pain - from tissue damage
- examples → trauma, surgery, injury
chronic pain - pain that lasts beyond the normal healing period of 3-6 months
- may be no identifiable cause → lower back pain, sickle cell anemia
order of total body assessment by systems - general health state
- nutrition and hydration
- skin, hair, nails
- head and neck
- eyes, ears, nose, mouth, and throat
- thorax and lungs
- heart, neck vessels, peripheral vascular
- breasts
- abdominal → gastrointestinal
- abdominal → urinary
- musculoskeletal
- neurological
- genitalia
- anus, rectum, and prostate
- endocrine and hematologic systems
considerations for the interview environment - limit distractions
- avoid using technical language
- avoid interrupting the patient
,NURS 328 - Final Exam Study Guide
phases of the interview process 1. pre-interaction phase
- compiling existing data
- preparing for patient interview from existing medical records
- looking at the patient's chart
2. beginning phase
- introduction
- state the purpose of the interview
3. working phase
- closed ended or direct questions for specific info
- open ended questions, broad answers in patient's words
- avoid "why" questions
4. closing phase
- summarizing
- stating the most important 2-3 problems or patterns
,NURS 328 - Final Exam Study Guide
emergency/life-threatening assessment - based on the mnemonic ABCDE
- A → airway
- B → breathing
- C → circulation
- D → disability
- E → exposure
comprehensive assessment - complete health history and physical assessment performed
- annually for outpatients
- upon hospital/long-term care admission
focused assessment - occurs in all settings
- smaller in scope but increased depth for specific issues
first-level priority patient - emergency, life-threatening, and immediate
- example → ABCs, bleeding out
second-level priority patient - requiring attention to avoid further deterioration
- example → sepsis, hypoglycemia
third-level priority patient - important to the patient's health but can be addressed after more urgent
problems are addressed
- example → UTIs, fracture
, NURS 328 - Final Exam Study Guide
allergy questions - verify allergies with patients and compare them to the allergies in their
chart
- note the type of response to the allergy → rash, throat swelling, difficulty
breathing, anaphylactic shock
- differentiate between an adverse reaction (nauseousness) and an allergic
reaction (throat swelling, difficulty breathing)
documentation of allergies - patient should have a name band applied noting the allergy
- allergies should be documented appropriately in the patient's chart
acute pain - from tissue damage
- examples → trauma, surgery, injury
chronic pain - pain that lasts beyond the normal healing period of 3-6 months
- may be no identifiable cause → lower back pain, sickle cell anemia
