Chapter 1 Flashcards
Subjective Data
A symptom (what a patient tells you they are feeling)
Objective Data
A sign (what vital signs or other assessment findings tell you)
Diagnostic Reasoning
Process of analyzing health data and drawing conclusions to identify diagnoses. Combination of deductive, inducting and abductive reasoning.
Abductive
Incomplete dataset to produce initial diagnosis
Deductive
Apply physiology and pathophysiology
Inductive
Signs/Symptoms
Clinical Judgement Model
Structure nursing education to enhance clinical judgement skills for novices.
5-step method
Assessment, diagnosis, planning, implementation, evaluation. ADPIE
Interdisciplinary Approach
People from different disciplines working together. Improves outcomes for complex care problems
First-Level Priority
Emergent, life threatening and requires immediate attention.
Second-Level priority -
Requires further attention to avoid deterioration but not as immediate as first level.
Third-Level Priority
Important to patient’s health but can be addressed after more urgent problems are.
1850
Nightingale
1970s
Evidence-based medicine term defined in the context of clinical research methods.
1970-1980
Focus on research utilization, now known as EBP (Evidence-based practice)
Complete total health database
Describes current and past health state and forms a baseline.
Focused or Problem-Centered Database
Collect “mini” database, more focused and smaller scope.
Follow-Up Database
Status of all identified problems should be evaluated at regular/appropriate intervals
Emergency Database
Rapid collection of data often compiled concurrently with life saving measures.
Holistic Model
Interdependent functioning of mind, body, and spirit to maintain optimal health.
Social Determinants of Health
Factors that influence well-being. E.g. environment, access to health care, community, education and economic stability. Impact of potential barriers
