Exam 1

Question 1

Health History: ADPIE

Assessment 🡪 collecting _______ and _______ ___

______ and most ______

May lead to inaccurate or inadequate, incorrect clinical judgements if completed incorrectly

ongoing and continuous through all phases!

More than just gathering information

Answer 1

Assessment 🡪 collecting subjective and objective data

first and most critical

May lead to inaccurate or inadequate, incorrect clinical judgements if completed incorrectly

ongoing and continuous through all phases!

More than just gathering information

Question 2

Health History: ADPIE

Diagnosis 🡪

Answer 2

analyzing subjective and objective data to make a professional nursing judgement (nursing diagnosis, collaborative problem, or referral)

Question 3

Health History: ADPIE

Planning 🡪

Answer 3

determining outcome criteria and developing a plan

Question 4

Health History: ADPIE

Implementation 🡪

Answer 4

Implementation 🡪 carrying out the plan

Question 5

Health History: ADPIE Evaluation 🡪

Answer 5

assessing whether outcome criteria have been met and revising the plan as necessary.

Question 6

Physical medical assessment 🡪

Answer 6

focuses primarily on the client’s physiologic development status

Question 7

Holistic Nursing Assessment 🡪

Answer 7

collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment

(Mind, body, and spirit interdependent factors that affect each client’s level of health)

Question 8

Health History: four basic sections-

Answer 8

History of Present Health Concern
Personal Health History
Family History
Lifestyle and health practices

Question 9

Types of nursing assessments: ______ or _____

Answer 9

Ongoing or partial:

Continued data collection after comprehensive assessment
Mini overview
Reassessed any problems
Detect any new problems

Question 10

Types of nursing assessments: (2)

Answer 10

Focused:

Does not replace comprehensive assessment
Thorough assessment of particular client problem
Does not address areas not related to problem

Question 11

Type of nursing assessments: (3)

Answer 11

Emergency:

• Very rapid assessment in life-threatening situations
• Goal = provide prompt treatment
• Only concern is preventing death

Question 12

Type of nursing assessments: (4)

Answer 12

Comprehensive:
- Subjective data
- Past health history
- Family history
- Lifestyle and health - practices
- Objective data
- Frequency depends on age, risk factors, health status, health promotion practices, lifestyle

Question 13

Steps of Health Assessment: step 1- preparing for assessment

Answer 13

Review clients record & status with other health care team members

Educate about client’s diagnosis and tests performed

Reflect on personal feelings regarding initial encounter with client

Obtain and organize materials needed for assessment.

Question 14

Steps of Health Assessment: step 2- collection of _____ data

Answer 14

Collection of subjective data – what the patient tells you

Biographical information

History of present health concern; physical symptoms related to each body part or system

Personal health history

Family history

Health and lifestyle practices

Review of systems

Question 15

Steps of Health Assessment step 3- Collection of objective data – what you observe

Answer 15

Physical characteristics
Appearance
Body functions
Behavior
Measurements
Results of lab tests

Question 16

Steps of Health Assessment step 4- ______ of data

Answer 16

Validation of data

Crucial part of assessment

Ensures assessment process is not ended before all relevant data have been collected

Helps prevent documentation of inaccurate data

Question 17

Steps of Health Assessment, step 5-

Answer 17

Documentation of data

Forms the database for entire nursing process

Provides data for all other members of health care team

Ensures valid conclusions are made

Question 18

***Steps tend to overlap – may perform 2-3 steps concurrently

Steps of Health Assessment: step 6-
Finally 🡪 analyzing cues to identify client concerns

Answer 18

Identify abnormal cues and supportive cues 🡪 cluster cues!

Draw inferences and identify and prioritize client concerns

Propose possible collaborative problems to
notify primary care giver

Identify need for referral to primary care provide

Document conclusions

Question 19

Components of health history assessments: 1

Answer 19

Biographic data:
a) Name, address, and phone number
b) Age, birth date, and birthplace
c) Gender (identification) and relationship status
d) Race and ethnic origin
e) Occupation: usual and present
f) Primary language

g) Source of history:
Judge reliability of informant and how willing he or she is to communicate - reliability leads to consistency of information (record who provides information)
Note any special circumstances, such as use of interpreter
Patient = primary source & all other sources (including health record) = secondary source

Question 20

Components of health history assessments: 2

Answer 20

Reason for seeking care:
a) What is your major health concern? How do you feel about having to seek care?

b) NOT a diagnostic statement

c) Symptom – subjective sensation, documented in “quotes”

d) Sign – objective abnormality detected on physical exam or lab reports

Question 21

COLDSPA- C

Answer 21

Character= s/s? descriptive terms?

Question 22

COLDSPA- O

Answer 22

Onset = when did it begin

Question 23

COLDSPA- L

Answer 23

Location = where is it? does it radiate?

Question 24

COLDSPA- D

Answer 24

Duration = how long? recurring

Question 25

COLDSPA- S

Answer 25

Severity = how bad? how much does it bother pt?

Question 26

COLDSPA- P

Answer 26

Pattern = what makes it better? what makes it worse?

Question 27

COLDSPA- A

Answer 27

Associated factors = other accompanying s/s and how it affects the pt

Question 28

Third component of health history assessment is

Answer 28

Present Health or HPI (COLDSPA, PQRSTU):

Question 29

PQRSTU (for pain)- P

Answer 29

Provocative
Palliative

what provokes or relieves pain?

Question 30

PQRSTU (for pain)- Q

Answer 30

Quality - describe character of pain (sharp, stabbing, aching)

Question 31

PQRSTU (for pain)- R

Answer 31

Radiates - is pain localized or does it radiate?

Question 32

PQRSTU (for pain)- S

Answer 32

Severity- how bad is the pain? interfere with ADLs or sleep? rate 1-10

Question 33

PQRSTU (for pain)- T

Answer 33

Timing- when does pain occur & how long does it last? how long before it reoccurs?

Question 34

PQRSTU (for pain)- U

Answer 34

Understand= pt’s perception of problem

Question 35

What is the purpose of the review of systems

Answer 35

Evaluate past and present state of each body system, assess all pertinent data relative to each body system & evaluate health promotion practices

Question 36

What is considered Holistic Patient care

Answer 36

Review of systems & Health Promotions

Question 37

Health Promotions 🡪

Answer 37

process of enabling people to increase control over, and to improve, their health.