NURS 6011 Exam Study Guide 1 Spring 2021
Health Assessment- Why, what different kinds are there?
o Is gathering information about the health status of the patient, analyzing and
synthesizing those data, making judgments about nursing interventions based on
the findings and evaluating patient care outcomes
o Deals with the nursing plan: ADPIE
o Subjective data: patient’s complaints, signs and symptoms, pain
o Objective data: concrete evidence, physical exam, vitals
o Types of nursing assessments:
Focused:
Follow-up, deals with 1-2 body systems. Depends on the patient’s
complaints, i.e. follow-up on a cough
Emergency:
Involves a life-threatening or unstable situation.
o Traumatic injury, stroke, MI
o A: airway, B: breathing, C: circulation, D: disability, E:
exposure
Comprehensive:
Full head to toe assessment, complete health record and physical
exam
o For a patient who is new to a clinic
Functional: health perception and health management
Head-to-toe assessment
Health history and interview (comprehensive and head to toe) pg. 27
o Therapeutic communication
Focuses on the patient and the patient’s concerns, help them work through
feelings and explore options related to situations
Caring, empathy, self concept (aware of own biases)
Non-verbal communication: through touch, posture, gestures, positioning
to patient
Active listening: focus on the patient and their perspectives
Restatement: make a simple statement, usually in the patient’s own words,
to get them to elaborate
Reflection: summarize the main points of the conversation
Elaboration: to more completely describe difficulties
Silence: to allow the patient to gather their thoughts
Focusing: when patient’s are straying off topic get them back on topic
Clarification
Summarizing: closure statement
Interviewing process
, o Preinteraction phase: collect data from the medical record, including previous
history of medical illnesses or surgeries, current medication list, and the problem
list all before seeing the patient.
o Beginning phase: introduce yourself by name and state the purpose of the
interview
o Working phase: collect data by asking specific questions
Closed-ended or direct questions: yes-no answers
Open-ended questions: require patients to give more info.
This is where you would chart the patient’s history and health problems
o Closing phase: end of the interview, summarize and stating two-three important
patterns or problems.
Nursing diagnoses- what is it?
o The clustering of data to make a judgment or statement about the patient’s
difficulty or condition
o The clinical judgment about an individual, their family or community responses to
actual or potential health difficulties/life processes. A nursing diagnosis provides
the basis for selection of nursing interventions to achieve outcomes for which the
nurse is accountable
Nursing process- what is it? Recognize each situation of assessment, diagnosis,
planning, implementation and evaluation.
o Is a systematic problem-solving approach to identifying and treating human
responses to actual or potential health difficulties. It serves as a framework for
providing individualized care not only to individuals but also to families and
communities. It is patient centered and focuses on solving problems and
enhancing strengths. It is applicable to patients in all stages of the life span and in
all settings
Assessing: begins with a complete and accurate health assessment to
promote health at its highest level. You set outcomes collaboratively with
patients.
Diagnose: provide a specific language and way of thinking. You use
diagnostic reasoning and critical thinking to formulate diagnostic
statements. Diagnoses may identify actual problems, risk for developing
problems and possible difficulties.
Planning: activities include determining resources, targeting nursing
interventions, and writing a care plan. The nursing plan requires that you
analyze the individual patient and his or her needs to provide
individualized and holistic care. You communicate the plan verbally and
write it in the patient’s chart.
Implementation: types include assessment, education, supervision,
coordination, referral, support, therapeutic communication, and technical
skills.
Evaluation: Is the judgment of the effectiveness of nursing care in meeting
the goals and outcomes. It is based on the patient’s responses to the
Health Assessment- Why, what different kinds are there?
o Is gathering information about the health status of the patient, analyzing and
synthesizing those data, making judgments about nursing interventions based on
the findings and evaluating patient care outcomes
o Deals with the nursing plan: ADPIE
o Subjective data: patient’s complaints, signs and symptoms, pain
o Objective data: concrete evidence, physical exam, vitals
o Types of nursing assessments:
Focused:
Follow-up, deals with 1-2 body systems. Depends on the patient’s
complaints, i.e. follow-up on a cough
Emergency:
Involves a life-threatening or unstable situation.
o Traumatic injury, stroke, MI
o A: airway, B: breathing, C: circulation, D: disability, E:
exposure
Comprehensive:
Full head to toe assessment, complete health record and physical
exam
o For a patient who is new to a clinic
Functional: health perception and health management
Head-to-toe assessment
Health history and interview (comprehensive and head to toe) pg. 27
o Therapeutic communication
Focuses on the patient and the patient’s concerns, help them work through
feelings and explore options related to situations
Caring, empathy, self concept (aware of own biases)
Non-verbal communication: through touch, posture, gestures, positioning
to patient
Active listening: focus on the patient and their perspectives
Restatement: make a simple statement, usually in the patient’s own words,
to get them to elaborate
Reflection: summarize the main points of the conversation
Elaboration: to more completely describe difficulties
Silence: to allow the patient to gather their thoughts
Focusing: when patient’s are straying off topic get them back on topic
Clarification
Summarizing: closure statement
Interviewing process
, o Preinteraction phase: collect data from the medical record, including previous
history of medical illnesses or surgeries, current medication list, and the problem
list all before seeing the patient.
o Beginning phase: introduce yourself by name and state the purpose of the
interview
o Working phase: collect data by asking specific questions
Closed-ended or direct questions: yes-no answers
Open-ended questions: require patients to give more info.
This is where you would chart the patient’s history and health problems
o Closing phase: end of the interview, summarize and stating two-three important
patterns or problems.
Nursing diagnoses- what is it?
o The clustering of data to make a judgment or statement about the patient’s
difficulty or condition
o The clinical judgment about an individual, their family or community responses to
actual or potential health difficulties/life processes. A nursing diagnosis provides
the basis for selection of nursing interventions to achieve outcomes for which the
nurse is accountable
Nursing process- what is it? Recognize each situation of assessment, diagnosis,
planning, implementation and evaluation.
o Is a systematic problem-solving approach to identifying and treating human
responses to actual or potential health difficulties. It serves as a framework for
providing individualized care not only to individuals but also to families and
communities. It is patient centered and focuses on solving problems and
enhancing strengths. It is applicable to patients in all stages of the life span and in
all settings
Assessing: begins with a complete and accurate health assessment to
promote health at its highest level. You set outcomes collaboratively with
patients.
Diagnose: provide a specific language and way of thinking. You use
diagnostic reasoning and critical thinking to formulate diagnostic
statements. Diagnoses may identify actual problems, risk for developing
problems and possible difficulties.
Planning: activities include determining resources, targeting nursing
interventions, and writing a care plan. The nursing plan requires that you
analyze the individual patient and his or her needs to provide
individualized and holistic care. You communicate the plan verbally and
write it in the patient’s chart.
Implementation: types include assessment, education, supervision,
coordination, referral, support, therapeutic communication, and technical
skills.
Evaluation: Is the judgment of the effectiveness of nursing care in meeting
the goals and outcomes. It is based on the patient’s responses to the
