NURS 3120 Exam 1 Study Guide
Ch. 1. Intro to Health Assessment
Define health & health assessment
Health: “a state of complete physical, mental, and social well-being and not merely the absence
of disease or infirmity”.
Health assessment: systematic data collection that provides information to facilitate a plan to
deliver the best care for every patient
Identify and explain the components of the health assessment
Health assessment: entails a comprehensive health history and a complete physical examination.
Health history
Physical and psychological issues, social, cultural, and spiritual beliefs,
identification of important data
Physical examination
Head to toe examination
What are the different facets of a patient’s health?
Six facets of a patient’s health are: physical, mental, social, cultural, developmental, and spiritual
o PMSCDS: Please make shoe costs dang slow
Ch. 2. Critical Thinking
Identify the components of the nursing process.
Assessment
Diagnosis
Planning
Implementations
Evaluation
Prioritize patient problems
Which of 4 things is most important, or something like that. Usually, ABCs, Safety, Pain, Other
stuff, risks. Depending on the situation, safety may have to come first, so ask yourself that.
Airway: Is the patient blowing snot or coughing up loogies (technical terms!)
everywhere? If they are unable to clear the airway alone, you might need to suction.
Breathing: How is the work of breathing? How are the patient oxygen sats (NOT
STATS!)? Is the patient pink? What are the breath sounds like?
Circulation: Often students miss the fact that circulation involves peripheral perfusion. If
your patient’s hands and feet are blue with delayed capillary refill time, the patient has a
circulation issue. Dehydration may present a circulation problem if the patient becomes
hypovolemic. Think about what a circulation problem would look like if you had no
, monitors to support you.
Pain: If the person is screaming an apparent agony, odds are their ABCs are okay. You
may need to check a blood pressure before you give meds, but sometimes it’s obvious
that the person’s BP is fine. (i.e. awake and screaming). If a pain scale is 4 or greater, we
should think about some kind of intervention.
Other stuff: might be “regular” kinds of problems, e.g. diarrhea, obesity, complications
of diabetes, etc.
Identify steps in developing a plan of care for patients.
What does OLDCARTS stand for? How does the nurse use it?
O: onset: when the sign of symptom began
-When did the headache begin?
L: location: where the sign or symptom is located
-Where exactly is the headache? Can you point to it? Does it radiate?
D: duration: how long the sign or symptom has been going on
C: characteristics
A: associated manifestations
R: relieving or exacerbating factors
T: treatment
S: severity
This is used to assess a patient’s chief complain 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 by nursing, biology, psychology,
sociology, and nutritional sciences, prioritized problem list, continues throughout patient
encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for remainder 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 have been attained, revised based
on patient’s condition and whether or not goals are realistic or necessary, ongoing and
confirms that patient care is relevant.
Ch. 1. Intro to Health Assessment
Define health & health assessment
Health: “a state of complete physical, mental, and social well-being and not merely the absence
of disease or infirmity”.
Health assessment: systematic data collection that provides information to facilitate a plan to
deliver the best care for every patient
Identify and explain the components of the health assessment
Health assessment: entails a comprehensive health history and a complete physical examination.
Health history
Physical and psychological issues, social, cultural, and spiritual beliefs,
identification of important data
Physical examination
Head to toe examination
What are the different facets of a patient’s health?
Six facets of a patient’s health are: physical, mental, social, cultural, developmental, and spiritual
o PMSCDS: Please make shoe costs dang slow
Ch. 2. Critical Thinking
Identify the components of the nursing process.
Assessment
Diagnosis
Planning
Implementations
Evaluation
Prioritize patient problems
Which of 4 things is most important, or something like that. Usually, ABCs, Safety, Pain, Other
stuff, risks. Depending on the situation, safety may have to come first, so ask yourself that.
Airway: Is the patient blowing snot or coughing up loogies (technical terms!)
everywhere? If they are unable to clear the airway alone, you might need to suction.
Breathing: How is the work of breathing? How are the patient oxygen sats (NOT
STATS!)? Is the patient pink? What are the breath sounds like?
Circulation: Often students miss the fact that circulation involves peripheral perfusion. If
your patient’s hands and feet are blue with delayed capillary refill time, the patient has a
circulation issue. Dehydration may present a circulation problem if the patient becomes
hypovolemic. Think about what a circulation problem would look like if you had no
, monitors to support you.
Pain: If the person is screaming an apparent agony, odds are their ABCs are okay. You
may need to check a blood pressure before you give meds, but sometimes it’s obvious
that the person’s BP is fine. (i.e. awake and screaming). If a pain scale is 4 or greater, we
should think about some kind of intervention.
Other stuff: might be “regular” kinds of problems, e.g. diarrhea, obesity, complications
of diabetes, etc.
Identify steps in developing a plan of care for patients.
What does OLDCARTS stand for? How does the nurse use it?
O: onset: when the sign of symptom began
-When did the headache begin?
L: location: where the sign or symptom is located
-Where exactly is the headache? Can you point to it? Does it radiate?
D: duration: how long the sign or symptom has been going on
C: characteristics
A: associated manifestations
R: relieving or exacerbating factors
T: treatment
S: severity
This is used to assess a patient’s chief complain 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 by nursing, biology, psychology,
sociology, and nutritional sciences, prioritized problem list, continues throughout patient
encounter.
Diagnosis: based on real or potential health problems, based on assessment data, sets
stage for remainder 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 have been attained, revised based
on patient’s condition and whether or not goals are realistic or necessary, ongoing and
confirms that patient care is relevant.
