Ch. 1: Introduction to Health Assessment
● Define health and health assessment
-Health: “A state of complete physical, mental, and social-well being and not merely the
absence of disease or infirmity.”
-Health Assessment: “The processes used to evaluate the health status of a person.”
● Explain the components of the health assessment
-Comprehensive health history: past medical, physical, psychological issues, social
history, cultural history, spiritual beliefs.
-Complete physical examination: head-to-toe, identify changes in patient’s body
systems, unusual or abnormal findings, document all findings in clear and concise manner,
collate all information with medical records.
● What are the different facets of a patient’s health?
-Spiritual, Developmental, Physical, Mental, Social, Cultural
Ch. 2: Critical Thinking
● Identify the components of the nursing process.
Assessment: gathering subjective and objective data, instrumental in devising care plan,
key points and relevant pieces of information grouped, prioritized problem list, continues
throughout patient encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for reminder of care plan, formulated based on problem
Planning: chart best course to address patient’s diagnosis, nurse and patient select
goals for each diagnosis, set short and long term goals, be realistic, work with patients
economic means competing responsibilities, family structure, and dynamics.
Implementation: completed by patient, family, or health care team, clearly relate to
nursing diagnosis, individualized for each patient, modified as changes occur, support positive
outcomes
Evaluation: continuing process to determine if goals are met, based on patient's
condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant.
● Prioritize patient problems.
-List the most active and serious problems first and record date of onset, order of priority,
separate lists for active and inactive problems, assign each problem a number to be referenced
in health record, use list to check status in future visits, allow other health care team members
to review status
● Identify steps in developing a plan of care for patients.
-Must be agreeable to patient, develop and record plan for each problem, specify what
steps are needed, share assessment with patient, ask the patient for his/her opinion, patient
should always be an active participant of plan, adapt and change as problem change.
● What does OLDCARTS stand for? How does the nurse use it?
, Onset
Location
Duration
Characteristics
Associated Manifestations
Relieving or Exacerbating Factors
Treatment
Severity
-This is used to assess a patient's chief complaint or pain they feel
● Know the different phases of the nursing process and what the nurse might be
doing in each of the phases.
Assessment: gathering subjective and objective data, instrumental in devising care plan,
key points and relevant pieces of information grouped, prioritized problem list, continues
throughout patient encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for reminder of care plan, formulated based on problem
Planning: chart best course to address patient’s diagnosis, nurse and patient select
goals for each diagnosis, set short and long term goals, be realistic, work with patients
economic means competing responsibilities, and family structure and dynamics.
Implementation: completed by patient, family, or health care team, clearly relate to
nursing diagnosis, individualized for each patient, modified as changes occur, support positive
outcomes
Evaluation: continuing process to determine if goals are met, based on patient's
condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant.
Ch. 3: Interviewing & Communication:
● Compare different therapeutic communication techniques which are used during
the patient interview.
-Active listening, guided questioning, nonverbal communication, empathic response,
validation, reassurance, summarization, transitions, empowering patient.
● Organize the phases of the nurse-patient interview.
-Pre-interview: set the stage, preparation
-Introduction: put patient at ease, establish trust
-Working: obtain patient information, set goal
-Termination: summarize and discuss goals
● Discuss strategies for handling difficult patients.
-Silent Patient, confusing patient, patient with altered capacity, talkative patient, crying
patient, angry/disruptive patient, language barrier, low literacy, impaired hearing, impaired
vision, cognitive disabilities, personal problems, and sexuality. **Need to finish filling in**
● Define health and health assessment
-Health: “A state of complete physical, mental, and social-well being and not merely the
absence of disease or infirmity.”
-Health Assessment: “The processes used to evaluate the health status of a person.”
● Explain the components of the health assessment
-Comprehensive health history: past medical, physical, psychological issues, social
history, cultural history, spiritual beliefs.
-Complete physical examination: head-to-toe, identify changes in patient’s body
systems, unusual or abnormal findings, document all findings in clear and concise manner,
collate all information with medical records.
● What are the different facets of a patient’s health?
-Spiritual, Developmental, Physical, Mental, Social, Cultural
Ch. 2: Critical Thinking
● Identify the components of the nursing process.
Assessment: gathering subjective and objective data, instrumental in devising care plan,
key points and relevant pieces of information grouped, prioritized problem list, continues
throughout patient encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for reminder of care plan, formulated based on problem
Planning: chart best course to address patient’s diagnosis, nurse and patient select
goals for each diagnosis, set short and long term goals, be realistic, work with patients
economic means competing responsibilities, family structure, and dynamics.
Implementation: completed by patient, family, or health care team, clearly relate to
nursing diagnosis, individualized for each patient, modified as changes occur, support positive
outcomes
Evaluation: continuing process to determine if goals are met, based on patient's
condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant.
● Prioritize patient problems.
-List the most active and serious problems first and record date of onset, order of priority,
separate lists for active and inactive problems, assign each problem a number to be referenced
in health record, use list to check status in future visits, allow other health care team members
to review status
● Identify steps in developing a plan of care for patients.
-Must be agreeable to patient, develop and record plan for each problem, specify what
steps are needed, share assessment with patient, ask the patient for his/her opinion, patient
should always be an active participant of plan, adapt and change as problem change.
● What does OLDCARTS stand for? How does the nurse use it?
, Onset
Location
Duration
Characteristics
Associated Manifestations
Relieving or Exacerbating Factors
Treatment
Severity
-This is used to assess a patient's chief complaint or pain they feel
● Know the different phases of the nursing process and what the nurse might be
doing in each of the phases.
Assessment: gathering subjective and objective data, instrumental in devising care plan,
key points and relevant pieces of information grouped, prioritized problem list, continues
throughout patient encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for reminder of care plan, formulated based on problem
Planning: chart best course to address patient’s diagnosis, nurse and patient select
goals for each diagnosis, set short and long term goals, be realistic, work with patients
economic means competing responsibilities, and family structure and dynamics.
Implementation: completed by patient, family, or health care team, clearly relate to
nursing diagnosis, individualized for each patient, modified as changes occur, support positive
outcomes
Evaluation: continuing process to determine if goals are met, based on patient's
condition, are goals realistic, it's an ongoing process, confirm nursing care is relevant.
Ch. 3: Interviewing & Communication:
● Compare different therapeutic communication techniques which are used during
the patient interview.
-Active listening, guided questioning, nonverbal communication, empathic response,
validation, reassurance, summarization, transitions, empowering patient.
● Organize the phases of the nurse-patient interview.
-Pre-interview: set the stage, preparation
-Introduction: put patient at ease, establish trust
-Working: obtain patient information, set goal
-Termination: summarize and discuss goals
● Discuss strategies for handling difficult patients.
-Silent Patient, confusing patient, patient with altered capacity, talkative patient, crying
patient, angry/disruptive patient, language barrier, low literacy, impaired hearing, impaired
vision, cognitive disabilities, personal problems, and sexuality. **Need to finish filling in**
