NR 302 – FINAL EXAM STUDY GUIDE
❖ Nurses’ role in health assessment
o ADPIE
o Assessment – collection of data from multiple sources
▪ Review of clinical record; interview; health history; physical examination;
functional assessment; cultural/spiritual assessment; consultation; review of
literature
o Diagnosis – interpretation of data by identifying clusters of cues so as to make inferences
▪ Compare clusters of cues with definitions and defining characteristics
▪ Validation on inferences based on findings
▪ Identify related factors
▪ Document the diagnosis
o Planning – establish priorities based on meeting identified patient care goals
▪ Develop outcomes and set time frames for meeting proposed outcomes
▪ Identify relevant interventions and utilize interdisciplinary health care team
members in the care planning process for the patient
▪ Document plan of care
o Implementation – determine patient readiness and involve patient in health care process
▪ Review planned interventions with interdisciplinary health care team members
to facilitate collaborative effort
▪ Utilize principles of delegation, being mindful of supervision and evaluation
▪ Counsel person and significant others
▪ Refer to continuing care
▪ Document care provided
o Evaluation – refer to established outcomes
▪ Evaluate individual’s condition and compare actual outcomes with expected
outcomes
▪ Summarize results of evaluation
▪ Identify reasons for failure to achieve expected outcomes
▪ Take corrective action to modify plan of care
▪ Document evaluation in plan of care
o Outcome Identification – identify expected outcomes related to patient individualization
▪ Ensure outcomes are realistic and measurable
▪ Specify short-term and long-term goal measurement criteria
❖ Interview and Health History
o Interview – subjective data collection; patient perception of health; first step in
therapeutic relationship
o Techniques of communication
▪ Introducing the interview
▪ Working phase
• Data-gathering phase
• Verbal skills include questions to patient and your responses to what’s
said
, ▪ TWO types of questions
• Open-ended
• Closed
• Each has a different place and function in interview
o Open-ended questions
▪ Ask for narrative responses
▪ State topic only in general terms
▪ Use in following situations:
• Begin interview
• Introduce a new section of questions
• Whenever the patient introduces a new topic
o Closed/Direct Questions
▪ Ask for specific information
▪ Elicit short one- or two-word answers, a yes or no answer, or a forced choice
▪ Use in following situations:
• After opening narrative to fill in details person may have left out
• When you need many specific facts about past health problems or
during review of systems
• To move the interview along
o Age appropriate style of questions
▪ Interviewing the caregiver
▪ Communicating with different ages across the life cycle
• Infants
• Toddlers and preschoolers
• School-age children
• Adolescents
• Adults and older adults
▪ Interviewing people with special needs
• Hearing impaired
• Acutely ill
• Under influence of street drugs/alcohol
• Those who must be asked personal questions
• Sexually aggressive
• Crying
• Angry/threatening violence
• Anxious
▪ Culture and Genetics
• Gender – being aware of maintaining cultural norms during interview
and exam process; maintaining privacy/modesty
• Sexual orientation – maintaining neutrality related to patient’s
presentation by being mindful of communication patterns; being aware
of your own personal bias and baggage
o History Taking
▪ Health history sequence
❖ Nurses’ role in health assessment
o ADPIE
o Assessment – collection of data from multiple sources
▪ Review of clinical record; interview; health history; physical examination;
functional assessment; cultural/spiritual assessment; consultation; review of
literature
o Diagnosis – interpretation of data by identifying clusters of cues so as to make inferences
▪ Compare clusters of cues with definitions and defining characteristics
▪ Validation on inferences based on findings
▪ Identify related factors
▪ Document the diagnosis
o Planning – establish priorities based on meeting identified patient care goals
▪ Develop outcomes and set time frames for meeting proposed outcomes
▪ Identify relevant interventions and utilize interdisciplinary health care team
members in the care planning process for the patient
▪ Document plan of care
o Implementation – determine patient readiness and involve patient in health care process
▪ Review planned interventions with interdisciplinary health care team members
to facilitate collaborative effort
▪ Utilize principles of delegation, being mindful of supervision and evaluation
▪ Counsel person and significant others
▪ Refer to continuing care
▪ Document care provided
o Evaluation – refer to established outcomes
▪ Evaluate individual’s condition and compare actual outcomes with expected
outcomes
▪ Summarize results of evaluation
▪ Identify reasons for failure to achieve expected outcomes
▪ Take corrective action to modify plan of care
▪ Document evaluation in plan of care
o Outcome Identification – identify expected outcomes related to patient individualization
▪ Ensure outcomes are realistic and measurable
▪ Specify short-term and long-term goal measurement criteria
❖ Interview and Health History
o Interview – subjective data collection; patient perception of health; first step in
therapeutic relationship
o Techniques of communication
▪ Introducing the interview
▪ Working phase
• Data-gathering phase
• Verbal skills include questions to patient and your responses to what’s
said
, ▪ TWO types of questions
• Open-ended
• Closed
• Each has a different place and function in interview
o Open-ended questions
▪ Ask for narrative responses
▪ State topic only in general terms
▪ Use in following situations:
• Begin interview
• Introduce a new section of questions
• Whenever the patient introduces a new topic
o Closed/Direct Questions
▪ Ask for specific information
▪ Elicit short one- or two-word answers, a yes or no answer, or a forced choice
▪ Use in following situations:
• After opening narrative to fill in details person may have left out
• When you need many specific facts about past health problems or
during review of systems
• To move the interview along
o Age appropriate style of questions
▪ Interviewing the caregiver
▪ Communicating with different ages across the life cycle
• Infants
• Toddlers and preschoolers
• School-age children
• Adolescents
• Adults and older adults
▪ Interviewing people with special needs
• Hearing impaired
• Acutely ill
• Under influence of street drugs/alcohol
• Those who must be asked personal questions
• Sexually aggressive
• Crying
• Angry/threatening violence
• Anxious
▪ Culture and Genetics
• Gender – being aware of maintaining cultural norms during interview
and exam process; maintaining privacy/modesty
• Sexual orientation – maintaining neutrality related to patient’s
presentation by being mindful of communication patterns; being aware
of your own personal bias and baggage
o History Taking
▪ Health history sequence
