NURS 3320 Holistic Health Assessment
FALL 2021 Exam 1 Study Guide
This first Exam includes the 4 chapters involved in the basics of Assessment –
... [Show More] Evidence-Based Assessment, The Interview, Health History and Assessment Techniques. Pay attention to charts and tables that help categorize and clarify information. I will point out whether certain elements are emphasized or whether there will not be a focus on them. Chapters 5 & 9 cover Mental Status & Vital Signs/General Survey/Measurement. Ch. 12 & 22 are the beginning of the “body system” chapters.
For every body system chapter: know the specific Structure & function (pay attention to my slides and the info below for areas I emphasize), Subjective data, including abnormal findings. Objective data – Exam across the lifespan; age specific findings and exam techniques, normals and abnormals. ALWAYS pay attention to my slides. Unless I indicate that something below is excluded from the material, info on my slides could be covered on the exam. Know HOW to perform the physical assessment. Always know the abnormal findings in the right shaded column) – for each chapter. This outline will give specific details, as well as those abnormals at the end of each chapter – narrowed down a bit.
Ch. 1 – Evidence-Based Assessment:
• A clinical body of evidence – validated the importance of using assessment techniques
• Assessment – first step of the Nursing Process, includes o Subjective and objective data o Database – gathering data
• Diagnostic reasoning o Forming hypotheses o Clustering data o Validation of data
• Critical Thinking and the Diagnostic Process (See Figure 1-2, p. 3)
• Nursing Process o Assessment (data collection)
o Diagnosis (clustering and interpreting testing hypotheses, validating diagnoses & documenting diagnoses).
o Outcome Identification (Goal): Identify expected outcomes, Individualize to the person, culturally appropriate, SMART Goal (Specific, Measurable, Attainable,
Realistic & Timed) o Planning (Establish priorities, Develop outcomes, Set timelines, Identify interventions, integrate evidence-based trends and research, document)
o Implementation (Put the plan in place); Collaborate with colleagues, provide teaching, document
o Evaluation – (Progress toward outcomes, conduct systematic, ongoing criterionbased evaluation, include patient and significant others),
• The way we apply the nursing process depends on our level and time of experience o Novice nurse (uses rules to guide performance) o Competent nurse (2-3 years in similar situations) o Proficient nurse ((Sees the patient as a whole v. list of tasks) o Expert nurse (Has intuitive grasp of a clinical situation)
• Critical thinking o The way of moving from novice to expert is through use of critical thinking o “Thinking about your thinking while thinking”
o
o “Thinking about your thinking while thinking” o Helps you:
• Analyze complex patient data
• Make decisions about patient’s problems
• Evaluate problems
• Decide on appropriate interventions o Don’t focus on the 17 assumptions, but how they fit in the nursing process
• DO KNOW about organizing and validating data, distinguishing normal from abnormal, clustering data, looking for patterns, and setting priorities especially. o Setting priorities Table 1-1, p. 5
• KNOW the difference in 1st, 2nd, 3rd level problems
• 1st level – ABCs and Vital signs concerns
• 2nd level – MUAAAR
• Mental Status Change
• Untreated medical problems requiring immediate attention
• Acute pain
• Acute urinary elimination problems
• Abnormal laboratory values
• Risks of infection, safety, or security
• 3rd level – (later priorities) activity, rest, family coping, teaching
• Types of nursing diagnoses o Actual: Existing problems that are amenable to independent nursing interventions o Risk: Potential problems that an individual does not currently have but is particularly vulnerable to developing; and
o Wellness: Focusing on strengths and reflect the individual’s transition to a higher level of wellness
• Evidence-based assessment o Evidence-based practice (EBP)
o Archie Cochrane – British epidemiologist who encouraged systematic reviews of randomized clinical trials to disseminate findings
o EBP is a systematic approach to practice that emphasizes the use of best evidence o Evidence has shown the need to revise certain assessment practices, i.e. using auscultation of bowel sounds as the best indicator of returning GI motility after surgery.
o Takes up to 17 years for research findings to be implemented into practice o Fostering a culture of EBP
• Collecting Four Types of Data o Complete (Total Health) database: Could be used in primary care, for well and ill people or in acute care (hospital)
• In hospital – gathered on admission to the hospital
• In clinic setting – Nurse is the first professional to see the patient and have responsibility for monitoring their health care
• Screens for pathology as well as response to health problems o Focused or Problem centered:
• For a limited or short-term problem, smaller scope, focused
• Typically one problem or one body system
• Used in hospital, primary care or long-term care o Follow-up database:
• Looking at change in problem at certain intervals
• Used in all settings to follow up short-term or chronic health problems
• Could be used in the hospital – routine shift assessment o Emergency database:
• Calls for rapid collection of data
• Often compiled concurrently with lifesaving measures o Description of each; when to use
• Health Promotion and disease prevention [Show Less]