Chapt 1: Evidence-Based Assessment Flashcards
What is subjective data?
What the person says about himself or herself during history taking.
What is objective data?
what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination.
What is the database?
The patient’s record and laboratory studies
What is diagnostic reasoning?
The process of analyzing health data and drawing conclusions to identify diagnoses.
What are the 4 components of diagnostic reasoning?
(1) attending to initially available cues;
(2) formulating diagnostic hypotheses;
(3) gathering data relative to the tentative hypotheses
(4) evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis
6 phases of the nursing process?
1) assessment
2) diagnosis
3) outcome identification
4) planning
5) implementation
6) evaluation
What are first level priority problems?
emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.
What are second-level priority problems?
those requiring your prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security).
What are third-level priority problems?
those that are important to the patient’s health but can be attended to after more urgent health problems are addressed. Interventions to treat these problems are long term.
What is evidence-based practice?
best-practice techniques to treat patients.
What are Complete (Total Health) Databases?
complete health history and a full physical examination.
What is Focused or Problem-Centered Database?
limited or short-term problem. Here you collect a “mini” database.
What is a Follow-Up Database?
status of any identified problems should be evaluated at regular and appropriate intervals.
What is an Emergency Database?
urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures.
What is holistic health?
Holistic health views the mind, body, and spirit as interdependent and functioning as a whole within the environment.
In a holistic model, assessment factors are expanded to include such things as lifestyle behaviors, culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations of life.
