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NUR 2092 Health Assessment Exam 1 Muskus 1
- 6 steps of nursing process
Answer Assessment Diagnosis
Outcome identification Planning Implementation Evaluation
- Assessment
Answer Interview, health history, ROS, physical examination, functional assessment, spiritual and cultural assessment
- Subjective data
Answer What patient SAYS
- Objective data
Answer What you OBSERVE
- SMART component in outcome identification
Answer Specific Measurable
Attainable Relevant Time bound
- evidence-based assessement
-depends on all four factors
Answer *Best evidence from a critical review of research literature 1 / 2
*The patient's own preferences *The clinician's own experience and expertise *Physical examination and assessment.
- Principles of setting priorities
- Make a complete list of current medications, medical problems, allergies, and reasons for
Answer
seeking care. Refer to them frequently because they may affect how you set priorities.
- Determine the relationships among the problems
Answer If problem Y causes problem Z, problem Y takes priority over problem Z
Setting priorities is a dynamic, changing process; at times, the order of priority changes, depending on the seriousness and relationship of the problems
- Second level priority
Answer requires attention to avoid further deterioration
metal status change, prior medical problems, acute pain, abnormal labs, risk of infection, subtle difference
- First level priority
-exception
Answer Emergent situations, life threading and needs immediate attention
• Airway problems
• Breathing problems
• Cardiac/circulation problems
• Vital sign concerns (e.g., high fever)
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