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N3320 Holistic Health Assessment
Exam 1 Study Guide
This first Exam includes the 5 chapters involved in the basics of Assessment –
The Nurse’s Role in Health Assessment: Collecting and Analyzing Data;
Collecting Subjective Data: The Interview and Health History;
Collecting Objective Data: The Physical Examination;
Validating and Documenting Data, and
Thinking Critically to Analyze Data and Make Informed Nursing Judgments.
Chapters 6 & 8 cover Assessing Mental Status and Substance Abuse and Assessing General
Status and Vital Signs
Ch. 14 Assessing Skin, Hair and Nails, and
Ch. 24 Assessing Musculoskeletal System are the beginning of the “body system” chapters.
Know the specific Conceptual Foundations or Structure & function,
Subjective data, including rationale;
Objective data including technique, normal and abnormal findings
Include relevant content for performing the assessments in the childbearing woman, newborns
and infants, children and adolescents, and older adults.
Ch. 1 – Nurse’s Role in Health Assessment: Collecting and Analyzing Data
1. Definition of nursing by the American Nurses Association
“the protection, promotion, and optimization of health and abilities, prevention of illness
and injury, alleviation of suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families, communities and
populations.”
Must have accurate client assessments in order to make decisions
2. Assessment in Nursing: American Nurses Association definition of assessment
Assessment is collection by the RN of comprehensive data pertinent to the patient’s
health or situation.
3. Nursing: Scope and Standards of Practice: The RN
Collects data in a systematic manner, prioritizes data collection; involves the patient and
family
Uses evidence-based assessment techniques
Synthesizes data and documents findings
Derives diagnoses based on assessment data
4. Texas Board of Nursing: Definition of assessment and role of the RN.
“The comprehensive assessment is the first step and lays the foundation for the nursing
process...is the initial and ongoing, extensive collection, analysis and interpretation of
data.”
“The RN must anticipate and recognize changes in patient conditions and determines
when reassessments are needed.”
Scope of practice for RNs: perform comprehensive nursing assessments and synthesize
data to formulate the plan of care.
5. Nursing Process and Assessment – ADPIE
, 2
Assessment: Collecting subjective and objective data
o The PURPOSE of health assessment- collect holistic subjective & objective data
to determine a client’s overall level of functioning in order to make a professional
clinical judgment (nursing diagnosis)
Diagnosis: Analyzing subjective and objective data to make a professional nursing
judgment (nursing diagnosis, collaborative problem, or referral)
Planning: Determining outcome criteria and developing a plan
Implementation: Carrying out the plan
Evaluation: Assessing whether outcome criteria have been met and revising the plan as
necessary
6. Nursing Process and Benner’s Model – Novice to Expert
7. Know the 4 types of assessment and examples of when each is used
Initial comprehensive assessment: Collection of subjective data about the client’s
perception of health of all body parts or systems, past medical history, family history, and
lifestyle and health practices. (admission to facility)
Ongoing or partial assessment: Data collection that occurs after the comprehensive
database is established. (reassessment, shift assessment)
Focused/problem-oriented assessment: assessment of a particular client problem, which
does not cover areas not related to the problem. (pain assessment)
Emergency assessment: Very rapid assessment performed in life-threatening situations.
(rapid response, chest pain, ABC)
8. Steps of health assessment
Collection of subjective data
Collection of objective data
Validation of assessment data for accuracy
Documentation of data which forms the database for communication with the health team
9. Preparing for the Assessment: Review this info
Review the client’s record FIRST- Gives info about educational level, occupation,
provides background about chronic diseases, ADLs (activities of daily living), current
health status
Educate yourself about diagnoses, tests
Avoid premature judgments (Chronic diseases, drug/alcohol use, lifestyle)
Gather supplies for assessment
N3320 Holistic Health Assessment
Exam 1 Study Guide
This first Exam includes the 5 chapters involved in the basics of Assessment –
The Nurse’s Role in Health Assessment: Collecting and Analyzing Data;
Collecting Subjective Data: The Interview and Health History;
Collecting Objective Data: The Physical Examination;
Validating and Documenting Data, and
Thinking Critically to Analyze Data and Make Informed Nursing Judgments.
Chapters 6 & 8 cover Assessing Mental Status and Substance Abuse and Assessing General
Status and Vital Signs
Ch. 14 Assessing Skin, Hair and Nails, and
Ch. 24 Assessing Musculoskeletal System are the beginning of the “body system” chapters.
Know the specific Conceptual Foundations or Structure & function,
Subjective data, including rationale;
Objective data including technique, normal and abnormal findings
Include relevant content for performing the assessments in the childbearing woman, newborns
and infants, children and adolescents, and older adults.
Ch. 1 – Nurse’s Role in Health Assessment: Collecting and Analyzing Data
1. Definition of nursing by the American Nurses Association
“the protection, promotion, and optimization of health and abilities, prevention of illness
and injury, alleviation of suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families, communities and
populations.”
Must have accurate client assessments in order to make decisions
2. Assessment in Nursing: American Nurses Association definition of assessment
Assessment is collection by the RN of comprehensive data pertinent to the patient’s
health or situation.
3. Nursing: Scope and Standards of Practice: The RN
Collects data in a systematic manner, prioritizes data collection; involves the patient and
family
Uses evidence-based assessment techniques
Synthesizes data and documents findings
Derives diagnoses based on assessment data
4. Texas Board of Nursing: Definition of assessment and role of the RN.
“The comprehensive assessment is the first step and lays the foundation for the nursing
process...is the initial and ongoing, extensive collection, analysis and interpretation of
data.”
“The RN must anticipate and recognize changes in patient conditions and determines
when reassessments are needed.”
Scope of practice for RNs: perform comprehensive nursing assessments and synthesize
data to formulate the plan of care.
5. Nursing Process and Assessment – ADPIE
, 2
Assessment: Collecting subjective and objective data
o The PURPOSE of health assessment- collect holistic subjective & objective data
to determine a client’s overall level of functioning in order to make a professional
clinical judgment (nursing diagnosis)
Diagnosis: Analyzing subjective and objective data to make a professional nursing
judgment (nursing diagnosis, collaborative problem, or referral)
Planning: Determining outcome criteria and developing a plan
Implementation: Carrying out the plan
Evaluation: Assessing whether outcome criteria have been met and revising the plan as
necessary
6. Nursing Process and Benner’s Model – Novice to Expert
7. Know the 4 types of assessment and examples of when each is used
Initial comprehensive assessment: Collection of subjective data about the client’s
perception of health of all body parts or systems, past medical history, family history, and
lifestyle and health practices. (admission to facility)
Ongoing or partial assessment: Data collection that occurs after the comprehensive
database is established. (reassessment, shift assessment)
Focused/problem-oriented assessment: assessment of a particular client problem, which
does not cover areas not related to the problem. (pain assessment)
Emergency assessment: Very rapid assessment performed in life-threatening situations.
(rapid response, chest pain, ABC)
8. Steps of health assessment
Collection of subjective data
Collection of objective data
Validation of assessment data for accuracy
Documentation of data which forms the database for communication with the health team
9. Preparing for the Assessment: Review this info
Review the client’s record FIRST- Gives info about educational level, occupation,
provides background about chronic diseases, ADLs (activities of daily living), current
health status
Educate yourself about diagnoses, tests
Avoid premature judgments (Chronic diseases, drug/alcohol use, lifestyle)
Gather supplies for assessment
