Nur 220 top tier test study guide
NUR 220 HEALTH ASSESSMENT IN NURSING
I. Evidence-based Health Assessment
a. Priority Levels
i. First level
1. Life threatening problems – LIFE THREATENING
a. AIR WAY PROBLEMS
b. BREATHING PROBLEMS
i. Rate, depth, pattern and breathing sounds
c. CIRCULATION PROBLEMS
i. Heart rate, BP, tissue perfusion, beating of the heart (what is their
EKG?)
ii. Second Level
1. Avoid deterioration
2. Change in mental status
3. Acute pain
a. Short term – 3to 6 months
b. Soft tissue i.e. sprains, paper cut
i. Gradually resolves
4. Acute Urinary elimination problems
5. Abnormal labs – life threatening
6. Risks of infection
7. Safety or security problems
8. DM w/ no insulin
iii. Third Level
1. These interventions take more time and are planned out over a long period of time
2. UTI – depending on what other issues are presented…
iv. Collaborative Problems
1. Physiological complication that nurses monitor for to detect the onset of changes in a
patient’s status. Nurses intervene in collaboration with other personnel from other
disciplines
a. Physical therapy, surgical wound
b. Types of Assessment:
i. Complete
1. Full physical – includes current and past health history
a. Review systems
ii. Focused/problem-centered/episodic
1. Problem-centered/episodic/focused
a. Whatever system is affecting them
b. Addresses specific problem
i. After asthma attack, cough, surgery
iii. Follow-up
1. Assessment after treatment
2. Determine status to see if treatment is working
3. Inform of side effects from treatment
Nur 220 Top tier Test study guide
,Nur 220 top tier test study guide
4. Relapse
iv. Emergency
Nur 220 Top tier Test study guide
,Nur 220 top tier test study guide
1. Rapid collection of data
a. Happens while life saving measures are being performed
II. General Survey
a. Components of the General Survey
i. First impression of a patient
1. Physical appearance
a. LOC: Alert, oriented, verbally responds, Motor response, Age, gender,
expression, facial features, signs of stress
2. Body structure: gait, posture, ROM, nutrition status, deformities (Accident or
hereditary), assistive devices
3. Behavior: Mood/affect, Eye contact, Speech, Dress, Grooming
III. The Interview
a. Interview Phases
i. Working phase
1. Data gathering phase
a. Obtain subjective (what the pt says) & objective data (what you obtain from
tests or observations)
b. Your verbal skills include ability to form questions appropriately and receive
appropriate from patient.
ii. Types of Interview Questions
1. Open ended questions
a. Why are you here? You said…tell me more? Anything else?
b. Responses are in paragraphs
2. Closed/direct questions
a. 1- or 2-word responses
b. Ask one question at a time
b. Communication: Verbal, Non-verbal, Therapeutic
i. Verbal: What you say to the patient
ii. Non-verbal – patients are more perceptive to this (how you act towards/around the
patient): Facial expressions, tone, posture, appearance, movement, eye contact, gestures,
iii. Therapeutic
1. What you do for the patient to make them feel more comfortable
2. What you do to alleviate symptoms, pain, and incorporate holistic care, i.e.
accommodating the patients physical, psychological, spiritual and social needs
a. Soothing music,
b. Speak in a soothing tone
c. Definitions and Examples of Signs and Symptoms
1. Signs: What you see i.e. Dislocated joint
ii. Symptoms (subjective)
1. What the patient feels i.e. older patients shrug off pain as a symptom of them getting
older à Pain (subjective)
IV. Vital Signs
a. Temperature
i. Sites
Nur 220 Top tier Test study guide
, Nur 220 top tier test study guide
1. Oral – 96.8-100.4
a. under the tongue
2. Temporal – 98.2-98.7
a. Lateral to hairline
3. Tympanic - 98.2-98.7
Nur 220 Top tier Test study guide
