NURS 301 HEALTH ASSESSMENT EXAM 1 FOCUS TOPICS TO REVIEW  

NURS 301 HEALTH ASSESSMENT EXAM 1 FOCUS TOPICS TO REVIEW  NURS 301 Health Assessment Exam 1 Focus Topics to Review 1. Explain the purpose of a nursing health assessment. (pg. 4) (a) Collecting holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgement 2. Compare and contrast medical assessment from nursing health assessment. (pg. 4) (a) A nursing assessment i. Physiological, psychological, sociocultural, developmental, and spiritual data about the client. ii. These are considered to be interdependent factors that affect a person level of health (b) A medical assessment focuses on disease and pathology. i. Focuses primarily on the client’s physiological status 3. Describe the phases of the nursing process involved in health assessment by the nurse. (pg. 3) (a) Assessment i. Collecting subjective and objective data (ex. Nurses assess patients by looking at medical history/chart, interviewing patients and obtaining vital signs/physical examination of patients.) (b) Diagnosis i. Analyzing subjective and objective data to make a professional nursing judgement – nursing diagnosis (ex. Nurses complete a diagnosis from the patient data collected during initial assessment. Impaired skin integrity related to fecal incontinence. (c) Planning i. Determining outcome criteria and developing a plan. (ex. Patient will remain free from infection throughout hospitalization(goal/outcome) by replacing patient's dressing with Neosporin ointment to wound and two dry 4x4 dressings secured with hypoallergenic tape once a shift: 14:00 - 21:00 - 06:00. (nursing intervention) (d) Implementation i. Carrying out the plan (ex. Changing a patient's wound dressing once a shift) (e) Evaluation i. Assessing whether outcome criteria have been met and revising the plan as necessary (ex. Re-assess patient vitals/physical exam, re-interview patient and discontinue or modify care plan based on goals/ outcomes met) 4. Compare and contrast subjective from objective data (pg. 7) (a) Subjective: what the patient says i. Sensations or symptoms i.e. pain, hunger, feelings, happiness, sadness, perceptions, desires, preferences, beliefs, ideas, values, and person information Objective ii. Biographical information, history of present health concern, personal health history, family history, health and lifestyle (b) Objective i. Examiner directly observes objective data or something the observer collect ii. Physical characteristics (skin color, posture), body functions (heart rate, respiratory rate), appearance (dress), behavior (mood swings), measurements (body temp, BP, height, weight), results of laboratory testing. 5. Compare and contrast the four basic types of nursing assessment: Give examples of what occurs in each phase. (pg. 5-6) (a) initial comprehensive : coming into the ER or Doc office i. involves collection of subjective data about the client's perception of his or her health of all body parts, past health history, family history, lifestyle and health practices, and objective data from step-by-step physical exam (b) ongoing or partial: being admitted to the hospital i. consists of data collection that occurs after the comprehensive database is established (this consists of a mini overview of the client’s body system and holistic health patterns as a follow up on health status) reassessed to determine any new changes or problems ex: lung cancer patient getting frequent assessments (c) focused/problem-oriented: going to the doctor for a specific reason i. a problem-oriented assessment does not replace the comprehensive health assessment ii. when a comprehensive database exists for a client who comes to the health care agency with a specific health concern iii. going to dermatologist (d) emergency: ambulance to ER i. very rapid assessment performed in life-threatening situations ii. choking, cardiac arrest, drowning, a FAST assessment is needed to provide prompt treatment. ex: evaluation of client's airway, breathing, circulation (ABC's) when cardiac arrest is suspected