lOMoARcPSD|44532475
Health Assessment Exam 3
10 questions nutrition
3 questions respiratory assessment
6 questions abdominal nutrition assessment
3 questions nursing process- evaluation
8 questions GI unit
9 questions GU unit
8 questions Respiratory unit
3 questions of med administration enteral feeds
Module 8: Evaluation
Evaluating Step:
● Nurse and patient together measure how well the patient has achieved the outcomes specified
in the care plan.
● Nurse identifies factors that contribute to the patient’s ability to achieve expected outcomes
and, when necessary, modifies the care plan
● The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct
future nurse-patient interactions
Actions Based on Patient Response to Care Plan:
● Terminate the care plan when each expected outcome is achieved
o Outcomes are very simple as in meeting a goal. Like getting up to go to the bathroom on
their own.
● Modify the care plan if there are difficulties achieving the outcomes
● Continue the care plan if more time is needed to achieve the outcomes
Four Types of Outcomes:
● Cognitive: increase in patient knowledge
o Examples: about medications taking, not smoking
● Psychomotor: patient’s achievement of new skills
o Example: newly diagnosed diabetic learning how to use glucose pen
● Affective: changes in patient values, beliefs, and attitudes
o Example: previously did not care now care based on health
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● Physiologic: physical changes in the patient
o Example: ambulation, pain improvement
Evaluating Outcomes:
● Cognitive: asking patient to repeat information or apply new knowledge
o Talk about medications and when to call the provider. Ask them to repeat it
back and evaluate if they understand.
● Psychomotor: asking patient to demonstrate new skill
o Show them how to use or do something. Then help them perform activity. Then
have them complete activity on their own.
● Affective: observing patient behavior and conversation
● Physiologic: using physical assessment skill to collect and compare data
o Worked on a goal with patient. Now physically observing if the patient can meet
that goal safely.
Five Classic Elements of Evaluation:
● Identifying evaluative criteria and standards
● Collecting data to determine if criteria and standards are met
● Interpreting and summarizing findings
● Documenting judgement
● Terminating, continuing, or modifying the plan
Evaluative Criteria V. Standards:
● Criteria: measurable qualities, attributes, or characteristics that specify skills, knowledge, or
health status
o Describe acceptable levels of performance by stating expected behaviors of nurse or
patient
● Standards: levels of performance accepted and expected by the nursing staff
o Established by authority, custom, or consent
Variable Affecting Outcome Achievement:
● Patient:
o Example: a patient gives up and refuses treatment
● Nurse:
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o Example: a nurse is suffering from burnout
● Healthcare system:
o Example: inadequate staffing
Evaluative Statements:
● Decide how well outcome was met
o Was it met, partially met, or not met and why was it met or not met.
● List patient data or behaviors that support decision
Revisions in the Care Plan:
● Delete or modifying the nursing diagnosis
● Make the outcome statement more realistic
● Increase the complexity of the outcome statement
● Adjust time criteria in the outcome statement
● Change nursing interventions
Institute of Medicine (IOM’s) 10 New Rules to Redesign and Improve Care:
● Care based on continuous healing relationships
● Customization based on patient needs and values
● The patient as the source of control
● Shared knowledge and the free flow of information
● Evidence-based decision making
● Safety as a system priority
● The need for transparency
● Anticipation of patient’s needs
● Continuous decrease in waste
● Cooperation among clinicians
● All have been written in order to base care or customize care according to the patients’ needs
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, lOMoARcPSD|44532475
Module 10- Respiratory Assessment
Anatomy & Physiology:
● Breathing
o Automatic
o Diaphragm: assists and helps with breathing
o Inspiration: muscles contract, thorax expands
o Expiration: muscles relax, thorax contracts
● Accessory Muscles:
o Muscles use with difficulty breathing
o Sternocleidomastoids
o Scalene
o Abdominal muscles
Health History:
● Common or Concerning Symptoms:
o Ask if they have a history of this experiencing currently or if they have it
o Shortness of breath (dyspnea)
o Wheezing
o Cough
o Blood-streaked sputum (hemoptysis)
o Purulent sputum
o Chest pain
● Overview:
o Any respiratory problems
o Cardiac problems
o Gastrointestinal problems
o Musculoskeletal problems
● Initial questioning should be broad, then get specific
o When did symptoms start, how did they start, how long has it occurred
o Not your job to diagnose medical condition, but want to ask enough questions to gather
enough information
● Dyspnea:
o Sudden onset: could be anaphylaxis, pulmonary embolism
o Spontaneous: pneumothorax, anxiety
● Wheezes:
o Partial airway obstruction, tissue inflammation, foreign body, asthma
● Cough:
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Health Assessment Exam 3
10 questions nutrition
3 questions respiratory assessment
6 questions abdominal nutrition assessment
3 questions nursing process- evaluation
8 questions GI unit
9 questions GU unit
8 questions Respiratory unit
3 questions of med administration enteral feeds
Module 8: Evaluation
Evaluating Step:
● Nurse and patient together measure how well the patient has achieved the outcomes specified
in the care plan.
● Nurse identifies factors that contribute to the patient’s ability to achieve expected outcomes
and, when necessary, modifies the care plan
● The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct
future nurse-patient interactions
Actions Based on Patient Response to Care Plan:
● Terminate the care plan when each expected outcome is achieved
o Outcomes are very simple as in meeting a goal. Like getting up to go to the bathroom on
their own.
● Modify the care plan if there are difficulties achieving the outcomes
● Continue the care plan if more time is needed to achieve the outcomes
Four Types of Outcomes:
● Cognitive: increase in patient knowledge
o Examples: about medications taking, not smoking
● Psychomotor: patient’s achievement of new skills
o Example: newly diagnosed diabetic learning how to use glucose pen
● Affective: changes in patient values, beliefs, and attitudes
o Example: previously did not care now care based on health
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
● Physiologic: physical changes in the patient
o Example: ambulation, pain improvement
Evaluating Outcomes:
● Cognitive: asking patient to repeat information or apply new knowledge
o Talk about medications and when to call the provider. Ask them to repeat it
back and evaluate if they understand.
● Psychomotor: asking patient to demonstrate new skill
o Show them how to use or do something. Then help them perform activity. Then
have them complete activity on their own.
● Affective: observing patient behavior and conversation
● Physiologic: using physical assessment skill to collect and compare data
o Worked on a goal with patient. Now physically observing if the patient can meet
that goal safely.
Five Classic Elements of Evaluation:
● Identifying evaluative criteria and standards
● Collecting data to determine if criteria and standards are met
● Interpreting and summarizing findings
● Documenting judgement
● Terminating, continuing, or modifying the plan
Evaluative Criteria V. Standards:
● Criteria: measurable qualities, attributes, or characteristics that specify skills, knowledge, or
health status
o Describe acceptable levels of performance by stating expected behaviors of nurse or
patient
● Standards: levels of performance accepted and expected by the nursing staff
o Established by authority, custom, or consent
Variable Affecting Outcome Achievement:
● Patient:
o Example: a patient gives up and refuses treatment
● Nurse:
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
o Example: a nurse is suffering from burnout
● Healthcare system:
o Example: inadequate staffing
Evaluative Statements:
● Decide how well outcome was met
o Was it met, partially met, or not met and why was it met or not met.
● List patient data or behaviors that support decision
Revisions in the Care Plan:
● Delete or modifying the nursing diagnosis
● Make the outcome statement more realistic
● Increase the complexity of the outcome statement
● Adjust time criteria in the outcome statement
● Change nursing interventions
Institute of Medicine (IOM’s) 10 New Rules to Redesign and Improve Care:
● Care based on continuous healing relationships
● Customization based on patient needs and values
● The patient as the source of control
● Shared knowledge and the free flow of information
● Evidence-based decision making
● Safety as a system priority
● The need for transparency
● Anticipation of patient’s needs
● Continuous decrease in waste
● Cooperation among clinicians
● All have been written in order to base care or customize care according to the patients’ needs
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
Module 10- Respiratory Assessment
Anatomy & Physiology:
● Breathing
o Automatic
o Diaphragm: assists and helps with breathing
o Inspiration: muscles contract, thorax expands
o Expiration: muscles relax, thorax contracts
● Accessory Muscles:
o Muscles use with difficulty breathing
o Sternocleidomastoids
o Scalene
o Abdominal muscles
Health History:
● Common or Concerning Symptoms:
o Ask if they have a history of this experiencing currently or if they have it
o Shortness of breath (dyspnea)
o Wheezing
o Cough
o Blood-streaked sputum (hemoptysis)
o Purulent sputum
o Chest pain
● Overview:
o Any respiratory problems
o Cardiac problems
o Gastrointestinal problems
o Musculoskeletal problems
● Initial questioning should be broad, then get specific
o When did symptoms start, how did they start, how long has it occurred
o Not your job to diagnose medical condition, but want to ask enough questions to gather
enough information
● Dyspnea:
o Sudden onset: could be anaphylaxis, pulmonary embolism
o Spontaneous: pneumothorax, anxiety
● Wheezes:
o Partial airway obstruction, tissue inflammation, foreign body, asthma
● Cough:
Downloaded by madiba South Africa stuvia ()
