Exam 1 Concepts
Chapter 1: Evidence-Based Assessment
Define and recognize examples of Subjective and Objective data
o Objective is obtained through observation and is verifiable; information gathered
from the patient by the use of observation, palpation, percussion, and auscultation,
as well as the use of instruments and techniques that provide specific
measurements
o Subjective is information that the patient shares about his or her health situation.
They are gathered through the patients report and are verifiable only by the
patient.
Identify order and tasks of each step of the Nursing Process
o ADPIE
o Assessment- information collection/ gathering data
o Diagnosis- information interpretation, stating problems & strengths
o Plan/ Outcome- setting nursing goals desired outcomes and planning
interventions
o Implementation- performing nursing interventions
o Evaluation- patient’s status and effectiveness of nursing interventions
Recognize the difference between different levels of Nursing Experience
o Novice: starting out in an area of learning; uses rules to guide performance
o Competency: building on 2 to 3 years of clinical experience; see actions in the
context of patient goals or plans
o Proficient: adding to time and experience; understands the patient situation as a
whole rather than individual parts-apply long term goals
o Expert: attained mastery of an area of learning; performs clinical judgement
using intuitive analysis
Define and identify examples of Levels of Priority: 1st, 2nd, and 3rd levels
o 1st level: emergent, life threatening, and immediate; like airway, breathing, and
circulation
o 2nd level: next in urgency, requiring attention so as to avoid further deterioration;
mental status changes, acute pain, infection risk, abnormal laboratory values, and
elimination problems
o 3rd level: important to patient’s health but can be addressed after more urgent
problems are addressed; like lack of knowledge, mobility problems, and family
coping
o Collaborative problems: approach to treatment involves multiple disciplines
Define the Four Types of Databases: Complete, Focused, Follow-Up, and Emergency
o Complete total health database describes current and past health state and forms
baselines to measure all future changes; complete physical examination; yields
first diagnosis
, o Focused or problem-centered database: collect “mini” database, smaller scope
and more focused than complete database; short term problem
o Follow-up database: status of all identified problems should be evaluated at
regular and appropriate intervals; follows up with both short- term and chronic
health problems; What change has occurred? Is the problem getting better or
worse?
o Emergency database: rapid collection of data often complied concurrently with
lifesaving measure; diagnosis must be swift and sure
Chapter 4: The Complete Health History
Identify components and purpose for
o Collect subjective data to combine with objective data from physical exam and
lab studies to from the database
o Provides a complete picture of patients past and present health status
o Can be used as a screening tool for detection of abnormalities
o Printed or electronic format that is available for review, validation, and updates
o Sequence may vary in terms of obtained information
o Those in primary care settings may use all of it, whereas those in a hospital may
focus primarily on the history of present illness and the functional, or patterns of
living, data.
HEALTH HISTORY SEQUENCE
o Biographic data:
Name, address, and phone number
Age, birth date, and birthplace
Gender (identification) and relationship status
Race and ethnic origin
Occupation: usual and present
Primary language
o Source of history:
Record who furnished information, usually the person, although source
may be relative or friend
Judge reliability of informant and how willing he or she is to communicate
Reliability leads to consistency of information
Note any special circumstances, such as use of interpreter
Identify how to perform a Review of Systems
o Evaluate past and present state of each body system
Assess that all pertinent data relative to each body system have been noted
Avoid writing in negative for body systems as you want to record either
presence of absence of symptoms
o Do not include objective data
o Limit to patient statements or subjective data
Chapter 1: Evidence-Based Assessment
Define and recognize examples of Subjective and Objective data
o Objective is obtained through observation and is verifiable; information gathered
from the patient by the use of observation, palpation, percussion, and auscultation,
as well as the use of instruments and techniques that provide specific
measurements
o Subjective is information that the patient shares about his or her health situation.
They are gathered through the patients report and are verifiable only by the
patient.
Identify order and tasks of each step of the Nursing Process
o ADPIE
o Assessment- information collection/ gathering data
o Diagnosis- information interpretation, stating problems & strengths
o Plan/ Outcome- setting nursing goals desired outcomes and planning
interventions
o Implementation- performing nursing interventions
o Evaluation- patient’s status and effectiveness of nursing interventions
Recognize the difference between different levels of Nursing Experience
o Novice: starting out in an area of learning; uses rules to guide performance
o Competency: building on 2 to 3 years of clinical experience; see actions in the
context of patient goals or plans
o Proficient: adding to time and experience; understands the patient situation as a
whole rather than individual parts-apply long term goals
o Expert: attained mastery of an area of learning; performs clinical judgement
using intuitive analysis
Define and identify examples of Levels of Priority: 1st, 2nd, and 3rd levels
o 1st level: emergent, life threatening, and immediate; like airway, breathing, and
circulation
o 2nd level: next in urgency, requiring attention so as to avoid further deterioration;
mental status changes, acute pain, infection risk, abnormal laboratory values, and
elimination problems
o 3rd level: important to patient’s health but can be addressed after more urgent
problems are addressed; like lack of knowledge, mobility problems, and family
coping
o Collaborative problems: approach to treatment involves multiple disciplines
Define the Four Types of Databases: Complete, Focused, Follow-Up, and Emergency
o Complete total health database describes current and past health state and forms
baselines to measure all future changes; complete physical examination; yields
first diagnosis
, o Focused or problem-centered database: collect “mini” database, smaller scope
and more focused than complete database; short term problem
o Follow-up database: status of all identified problems should be evaluated at
regular and appropriate intervals; follows up with both short- term and chronic
health problems; What change has occurred? Is the problem getting better or
worse?
o Emergency database: rapid collection of data often complied concurrently with
lifesaving measure; diagnosis must be swift and sure
Chapter 4: The Complete Health History
Identify components and purpose for
o Collect subjective data to combine with objective data from physical exam and
lab studies to from the database
o Provides a complete picture of patients past and present health status
o Can be used as a screening tool for detection of abnormalities
o Printed or electronic format that is available for review, validation, and updates
o Sequence may vary in terms of obtained information
o Those in primary care settings may use all of it, whereas those in a hospital may
focus primarily on the history of present illness and the functional, or patterns of
living, data.
HEALTH HISTORY SEQUENCE
o Biographic data:
Name, address, and phone number
Age, birth date, and birthplace
Gender (identification) and relationship status
Race and ethnic origin
Occupation: usual and present
Primary language
o Source of history:
Record who furnished information, usually the person, although source
may be relative or friend
Judge reliability of informant and how willing he or she is to communicate
Reliability leads to consistency of information
Note any special circumstances, such as use of interpreter
Identify how to perform a Review of Systems
o Evaluate past and present state of each body system
Assess that all pertinent data relative to each body system have been noted
Avoid writing in negative for body systems as you want to record either
presence of absence of symptoms
o Do not include objective data
o Limit to patient statements or subjective data
