NURS 340 Exam 1 Study Set With Questions and Answers
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Course
NUR 340
Institution
NUR 340
Subjective data information gathered from interview/history taking -what the patient tells you or what the patient STATES -you can't prove or observe the data -EX. Pain
Objective data information from your physical exam -what is OBSERVED by inspecting, percussing, palpating, auscultating EX. BP, h...
NURS 340 Exam 1 Study Set With
Questions and Answers
Subjective data ✅information gathered from interview/history taking
-what the patient tells you or what the patient STATES
-you can't prove or observe the data
-EX. Pain
Objective data ✅information from your physical exam
-what is OBSERVED by inspecting, percussing, palpating, auscultating
EX. BP, heart rate, vital signs
5 steps of nursing process (ADPIE) ✅-assessment
-diagnosis
-planning
-intervention
-evaluation
Elements that are included in the assessment phase of the nursing process ✅-process
used to evaluate the health status of a person
-systemic data collection that provides information to facilitate a plan to deliver the best
care
Purpose of the health assessment ✅-determine a patients health status
-determine patients risk factors
-determine the need for health education
-develop a nursing plan of care
Complete health database ✅describes current and past health state and forms
baseline to measure all future changes
What is included in a complete health database ✅-a complete health history
-full physical examination
-yielding the first diagnosis
A comprehensive health assessment includes ✅-patients current health problems
-past history
-family history
-review of body systems
-health patterns
When to obtain a complete health history ✅-every person needs a complete health
assessment
,-ideally done on admission
-appropriate for new patients in all settings (nursing home, home health care, new
patients to a clinic)
3 types of databases ✅focused, follow-up, emergency
Focused (episodic/problem-centered) database ✅-used for limited or short term
problem
-appropriate for established patients
-smaller in scope and more targeted that complete
EX. Labor and delivery
Follow-up database ✅-evaluates the status of any identified problem at regular
intervals to follow-up on short-term and chronic health problems
-evaluation of a previously identified problems
EX. Patient had a hip replacement and came back to hospital 14 days later for check up
Emergency database ✅-call for rapid collection of crucial data
-rapid assessment often occurs while performing lifesaving measures
-assessing physically and TREATING
Sign ✅an objective, observable phenomenon that can be identified by another person
Symptom ✅a subjective experience that cannot be identified by anyone else
Evidence based practice ✅is a systematic approach to practice that uses research
evidence, clinical expertise, clinician knowledge, and the patients preferences and
values to make decisions about care and treatment
-multifaceted and reflects holistic care
Health ✅relative state in which a person strives to meet their potential and includes the
area of wellness with the ultimate goal of improving health
-not solely defined as the absence of disease but rather by the contributions of all
dimensions
8 dimensions of health ✅-physical
-social
-emotional
-spiritual
-environmental
-intellectual
-financial
-occupational wellness
Best to work with the patient to enable partnering in choices allows for better outcomes
, Social determinants of health (SDOH) includes ✅-economic stability
-education
-social and community context
-neighborhood
-environment
-health and healthcare
Social determinants of health ✅-proven to affect a persons health and are the effects
of where people work, live, play, and learn
-associated with health risks and outcomes
-addressing positively impacts the health or people and takes a step forward in
achieving health equity
-reminding ourselves how they may affect each person individually is important in
determining the plan of care
Health disparities (health inequity/inequality) ✅driven by social and economic
inequities
-economic stability, neighborhood, and environment, education, food, community,
safety, and social context, health care system
Health and health care disparities ✅refer to differences in health and health care
between groups that stem from broader inequities
CDC identifies health disparities as ✅preventable differences in the burden on
disease, injury, violence, or opportunities to achieve optimal health that are experienced
by socially disadvantaged populations
Identifying data and source of the history ✅Biographic date= name, DOB, sex,
occupation, marital status, language
Source of history=from patient or the family, medical record, letter, or referral
-note any special circumstances such as use of interpreter
-note whether the patient appears well or ill (for reliability)
Chief complaints ✅-use direct quotes as much as possible
= reason for seeking care
-focus on patients prioritized reasons for seeking care
History of present illness (HPI) ✅-telling the story
-section is complete, clear, and chronologic account of the problems prompting the
patient to seek care
For well person=briefly note general state of health
Sick person=chronologically record the reason for seeking care
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