Summary Cultural Nursing and Assessment Exam 1- Study Guide

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