NUR 2092 Exam 1 Health Assessment

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NUR 2092 Exam 1 Health Assessment

• What are the steps in the Nursing Process?
• Assessment- collection of data from multiple sources (physical exam, health

history, review records)

• Diagnosis- cluster data that seems to be associated, validate info, look for gaps in

info, interpret data and identify problems

• Outcome identification- Identify expected outcomes set a SMART goal
• Planning- establish priorities, document plan of care, set time frames for meeting

goals

• Implementation- provide teaching and health promotion, use evidence based

interventions

• Evaluation- evaluate individuals condition and compare actual outcomes to

expected outcomes, and possibly modify plan

• What is subjective Data?
• What the patient says about him or herself.
• What is objective Data?
• What we observe when inspecting and assessing the patient
• What is a SMART goal?
• Specific
• Measurable
• Attainable
• Relevant
• Time-Bound
• What is evidence based clinical decision making?
• Review of research and literature, providers clinical expertise, patients

preferences and values

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• What are the two parts to communicating?
• Sending- verbal and nonverbal
• Receiving- interpretation based on past experiences, culture, and self-concept;

physical and emotional state.

• What is the key with communication?
• Is the receiver receiving the information the way you want it to come across?
• How do you prepare for an interview?
• Privacy
• No interuptions
• Physical environment
• Temperature

ii. Noise level iii. Light level iv. Distance (4-5 ft)

• No distractions

vi. Seating

• Limit note taking

• What is a closed ended question?
• A question that allows only a yes or no answer.
• When is a closed ended question used?
• To gain specific information
• What is an opened ended question?
• A question that allows for a narrative answer.
• When is an opened ended question used?
• To hear the pts feelings and opinions
• To develop rapport

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• What is a facilitation response?
• Mm-hmm, uh-huh
• What does a silence response do?
• Allow time to think
• What is a reflection response?
• “It’s hard to get up in the morning” ---- “You have difficulty getting the day

started”

• What is an empathy response?
• “I can’t do anything for myself anymore.” ----- “It must be difficult not being

independent, losing control”

• What are some barriers to communication?
• Lack of interest
• Physical barriers like a curtain, door, computer, pain, room temp.
• Hearing deficit
• Safety
• Psychological barriers- embarrassment, disbelief, anger, fear, grief, fatigue
• Language barrier
• Medical jargon
• What are the types of pain and causes?
• Nociceptive Pain
• Usually acute

ii. Starts outside the nervous system iii. From actual potential damages such as fracture or surgery iv. Responsive to anti-inflammatories and opiates

• Neuropathic Pain
• Abnormal processing from injury to nerve fibers or central nervous

system

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ii. Chronic iii. Pt normally feels numbness, tingling, shooting, burning, or phantom pain iv. Poorly responsive to pain meds

• Referred Pain
• Felt at a site different from the organ affected

ii. Spinal nerve and brain can not differentiate

• Phantom Pain
• Brain still getting messages

ii. Pain where a limb used to exist

• Acute Pain
• Short term

ii. Tissue damage iii. Self protective mechanism iv. Mild- moderate pain= sympathetic nervous system response

• Severe Pain= parasympathetic nervous system response
• Chronic Pain
• Over 6 months

ii. Adaptive response iii. Does not stop when injury heals iv. Abnormal processing of pain fibers from peripheral and central sites

• Breakthrough Pain
• Starts again or worsens before next scheduled medication dose
• What are behaviors of someone in acute pain?
• Guarding
• Grimacing
• Restlessness