NURSING FOUNDATIONS- ASSESSMENT & CULTURAL CARE – EXAM
CHEAT SHEET
1. Types of Assessment Data
Assessment
Ongoing process of collecting patient health information beginning at first contact
Includes subjective data, objective data, and diagnostic/lab results
Forms the foundation for clinical reasoning and diagnosis
Subjective Data
Information reported directly by the patient during history taking
Includes:
o Biographical data (age, occupation, religion, etc.)
o Chief complaint and current health concerns
o Past medical history, family history
o Lifestyle habits (diet, activity, substance use, relationships)
Example: “I think I broke my ankle.”
Objective Data
Data observed or measured by the healthcare provider during examination
Collected through inspection, palpation, percussion, and auscultation
Includes:
o Vital signs (BP, HR, RR, temp)
o Physical appearance (skin, posture, hygiene, behavior)
o Functional findings (gait, mood, respiratory effort)
o Diagnostic results (labs, imaging)
Example: swelling, bruising, abnormal vital signs, guarding behavior
Database
Combination of subjective data, objective data, medical history, and lab results
Used to support clinical judgment and identify health problems
2. Objective Patient Data
Information obtained through physical examination and measurement
Examples include:
o Vital signs
o Posture and gait
o Physical appearance and hygiene
o Observable behaviors and responses
3. Types of Databases
Complete (Total Health) Database
Comprehensive health history and full physical exam
Establishes baseline for future comparison
Common in primary care or admission assessments
Includes:
, o Health history, risk factors, coping patterns, and lifestyle
In hospitals:
o Physicians focus on pathology
o Nurses focus on functional status, coping, ADLs, and responses to illness
Focused (Problem-Centered) Database
Narrow assessment targeting a specific issue or system
Used for a single problem or symptom cluster
Common in all healthcare settings
Example: post-op patient develops cough → respiratory/cardiac assessment
Follow-Up Database
Ongoing reassessment of known health problems
Used to evaluate response to treatment and disease progression
Example: monitoring diabetes, hypertension, or heart failure over time
Emergency Database
Rapid data collection in life-threatening situations
Often done while lifesaving care is in progress
May rely on family or bystanders if patient is unresponsive
Example: overdose assessment while simultaneously managing airway, breathing, and
circulation
4. Health Promotion Model
Holistic Health
Views the person as a whole (physical, emotional, social, cultural, spiritual)
Considers environment, lifestyle, stress, coping, and development
Health Promotion & Disease Prevention
Focuses on supporting healthy behaviors and preventing illness
Includes screening, counseling, and preventive interventions
Common preventive care includes:
Screening: BP, BMI, cervical cancer, HIV
Lifestyle assessment: diet, exercise, substance use, sexual health
Counseling: nutrition, physical activity, risk reduction
Chemoprophylaxis: folic acid, vitamins when indicated
5. Clustering Data
Cue: Any sign, symptom, or lab finding
After data collection, group related findings into meaningful patterns
Helps identify likely health problems and clinical diagnoses
Supports differential diagnosis by:
o Linking related findings
o Identifying consistent patterns
o Eliminating unrelated data
Example:
Acute pain cluster → increased HR, elevated BP, anxiety
, 6. Priority Setting of Problems
First-Level (Highest Priority)
Life-threatening issues requiring immediate action
o Think about your ABCs- Airway, Respiratory, Cardiac
Example: airway obstruction, respiratory failure
Second-Level
Conditions requiring prompt attention to prevent worsening
Includes:
o Acute pain
o Infection risk
o Mental status changes
o Abnormal labs
o Safety risks
Third-Level
Non-urgent but still important issues
Addressed after immediate concerns are managed
Includes:
o Knowledge deficits
o Long-term mobility issues
o Family coping problems
Often requires collaborative care (e.g., physical therapy)
7. Cultural Aspects of Pain
Pain is universal but experienced differently across cultures
Culture influences:
o Pain perception
o Pain expression
o Pain tolerance
o Meaning assigned to pain
Individual beliefs and experiences shape response to pain
8. Culturally Competent Care
Ability to provide appropriate care to diverse populations
Includes awareness of:
o Cultural differences
o Immigration status
o Social stressors
o Family structure and beliefs
Goal is to improve communication, trust, and outcomes
9. Cultural Assessment
Key Principle
CHEAT SHEET
1. Types of Assessment Data
Assessment
Ongoing process of collecting patient health information beginning at first contact
Includes subjective data, objective data, and diagnostic/lab results
Forms the foundation for clinical reasoning and diagnosis
Subjective Data
Information reported directly by the patient during history taking
Includes:
o Biographical data (age, occupation, religion, etc.)
o Chief complaint and current health concerns
o Past medical history, family history
o Lifestyle habits (diet, activity, substance use, relationships)
Example: “I think I broke my ankle.”
Objective Data
Data observed or measured by the healthcare provider during examination
Collected through inspection, palpation, percussion, and auscultation
Includes:
o Vital signs (BP, HR, RR, temp)
o Physical appearance (skin, posture, hygiene, behavior)
o Functional findings (gait, mood, respiratory effort)
o Diagnostic results (labs, imaging)
Example: swelling, bruising, abnormal vital signs, guarding behavior
Database
Combination of subjective data, objective data, medical history, and lab results
Used to support clinical judgment and identify health problems
2. Objective Patient Data
Information obtained through physical examination and measurement
Examples include:
o Vital signs
o Posture and gait
o Physical appearance and hygiene
o Observable behaviors and responses
3. Types of Databases
Complete (Total Health) Database
Comprehensive health history and full physical exam
Establishes baseline for future comparison
Common in primary care or admission assessments
Includes:
, o Health history, risk factors, coping patterns, and lifestyle
In hospitals:
o Physicians focus on pathology
o Nurses focus on functional status, coping, ADLs, and responses to illness
Focused (Problem-Centered) Database
Narrow assessment targeting a specific issue or system
Used for a single problem or symptom cluster
Common in all healthcare settings
Example: post-op patient develops cough → respiratory/cardiac assessment
Follow-Up Database
Ongoing reassessment of known health problems
Used to evaluate response to treatment and disease progression
Example: monitoring diabetes, hypertension, or heart failure over time
Emergency Database
Rapid data collection in life-threatening situations
Often done while lifesaving care is in progress
May rely on family or bystanders if patient is unresponsive
Example: overdose assessment while simultaneously managing airway, breathing, and
circulation
4. Health Promotion Model
Holistic Health
Views the person as a whole (physical, emotional, social, cultural, spiritual)
Considers environment, lifestyle, stress, coping, and development
Health Promotion & Disease Prevention
Focuses on supporting healthy behaviors and preventing illness
Includes screening, counseling, and preventive interventions
Common preventive care includes:
Screening: BP, BMI, cervical cancer, HIV
Lifestyle assessment: diet, exercise, substance use, sexual health
Counseling: nutrition, physical activity, risk reduction
Chemoprophylaxis: folic acid, vitamins when indicated
5. Clustering Data
Cue: Any sign, symptom, or lab finding
After data collection, group related findings into meaningful patterns
Helps identify likely health problems and clinical diagnoses
Supports differential diagnosis by:
o Linking related findings
o Identifying consistent patterns
o Eliminating unrelated data
Example:
Acute pain cluster → increased HR, elevated BP, anxiety
, 6. Priority Setting of Problems
First-Level (Highest Priority)
Life-threatening issues requiring immediate action
o Think about your ABCs- Airway, Respiratory, Cardiac
Example: airway obstruction, respiratory failure
Second-Level
Conditions requiring prompt attention to prevent worsening
Includes:
o Acute pain
o Infection risk
o Mental status changes
o Abnormal labs
o Safety risks
Third-Level
Non-urgent but still important issues
Addressed after immediate concerns are managed
Includes:
o Knowledge deficits
o Long-term mobility issues
o Family coping problems
Often requires collaborative care (e.g., physical therapy)
7. Cultural Aspects of Pain
Pain is universal but experienced differently across cultures
Culture influences:
o Pain perception
o Pain expression
o Pain tolerance
o Meaning assigned to pain
Individual beliefs and experiences shape response to pain
8. Culturally Competent Care
Ability to provide appropriate care to diverse populations
Includes awareness of:
o Cultural differences
o Immigration status
o Social stressors
o Family structure and beliefs
Goal is to improve communication, trust, and outcomes
9. Cultural Assessment
Key Principle
