Ch. 1 (Evidence-Based Assessment) Flashcards
What type of data involves what the person says during history taking?
subjective data
What two types of data in a health assessment form the database?
- subjective data
- objective data
What type of data involves what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examinations?
objective data
What’s the purpose of the health assessment?
to make a judgement or diagnosis (relative to the patient’s health state, response to actual/potential health problems and life processes)
Subjective and objective data come together to form what?
the database
What’s the process of analyzing health data and drawing conclusions to identify diagnoses?
diagnostic reasoning
What should one do to assessment data that appears casual or associated to one another?
cluster or group them together
What are the five steps in the nursing processing?
clinical judgement and the diagnostic process
- assessment
- diagnosis
- planning
- implementation
- evaluation
What is the first stage in the nursing process and what do you do during it?
clincial judgement and the diagnostic process
- assessment
- gather data from medical records and patient and complete assessment
What is the second stage in the nursing process and what do you do during it?
clincial judgement and the diagnostic process
- diagnosis
- clincial findings are interpreted and clinical judgement is used to determine a diagnosis
What is the third stage in the nursing process and what do you do during it?
clincial judgement and the diagnostic process
- planning
- formulate goals and outcomes in collaboration with the patient
What is the fourth stage in the nursing process and what do you do during it?
clincial judgement and the diagnostic process
- implementation
- implement the plan and evaluate the results
What is the fifth stage in the nursing process and what do you do during it?
clincial judgement and the diagnostic process
- evaluation
- reasses or change the original plan
In relation to the nursing process…
What kind of nurse has no experience with specific patient populations and uses rules to guide performacne and achieve competency?
novice nurse
in relation to the nursing process…
What kind of nurse understands a patient’s situation as a whole rather than a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it?
proficient nurse
In relation to the nursing process…
Waht kind of nurse has an intuitive grasp of a clinical sitaution and zeroes in on the accurate solution?
expert nurse
What kind of thinking is defined by the means by which we learn to asses and modify, if indicated, before acting?
critical thinking
During critical thinking, priorities are considered.
What priority problems are emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing?
first-level priority problems
During critical thinking, priorities are considered.
What priority problems are next in urgency, and require prompt intervention to prevent further deterioration such as mental status change, acute pain, or abnormal lab values in the patient?
second-level priority problems
During critical thinking, priorities are considered.
What priority problems are important to the patient’s health but can be addressed after more urgent problems?
third-level priority problems
What are certain physiologic conditions in which the approach to treatment involves multiple disciplines?
collaborative problems
What systematic approach to practice uses research evidence, clincial expertise, clinician knowledge, and the patient’s preferences and values to make decisions about care and treatment?
evidence-based practice
Evidence-based practice uses what four types of databases?
- complete (or total health) database
- focused (or problem-centered) database
- follow-up database
- emergency database
What kind of database includes a complete health history and a full physical examination, yielding the first diagnoses?
complete (or total health) database
What kind of database is used for a limited or short-term problem?
focused (or problem-centered) database
What kind of database evaluates the status of any identitifed problem at regular intervals to follow up on short-term and chronic health problems?
follow-up database
What kind of database calls for rapid collection of crucial data, which often occurs while performing lifesaving measures?
emergency database
