Chapter 1 Flashcards

1
Q

Subjective data

A

What the person says themselves during the interview

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2
Q

Objective data

A

What you observe by inspection, percussing, palpating, and auscultating

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3
Q

Purpose of assessment

A

To make judgment or diagnosis

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4
Q

Data base

A

Subjective, objective, patients record, and lab studies

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5
Q

Diagnostic reasoning

A

The process of analyzing health data and drawing conclusions to identify diagnoses

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6
Q

Four components to diagnostic reasoning

A

1) Attending to initially available cues
2) Formulating diagnostic hypothesis
3) Gathering data relative to tentative hypotheses
4) Evaluating each hypothesis with new data collected (driving at final diagnosis)

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7
Q

Cues

A

A piece of information, sign, symptom, or piece of lab data

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8
Q

Hypothesis

A

tentative explanation for a cue or set of cues that can be used as a basis for further investigation

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9
Q

Parts of the nursing process

A
Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluate
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10
Q

Critical thinking enables you to

A
  • Analyze complex data
  • Make decisions about patient problems and alternatives
  • Evaluate each problem to decide which applies
  • Decide on most appropriate interventions based on situation
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11
Q

Identify assumptions

A

Dont assume anything before you gather the facts

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12
Q

Validate

A

always validate information

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13
Q

Distinguish normal from abnormal

A

Ensure you know your patient’s normal

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14
Q

Identify and…

A

organize comprehensive approach to assessment

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15
Q

Make inferences

A

Drawing valid conclusions

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16
Q

Clustering related cues

A

Cluster alike information to sort the information

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17
Q

Distinguish

A

relevant from irrelevant

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18
Q

Recognize inconsistencies

A

Is the person’s story changing?

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19
Q

Identify…

A

Patterns and missing information

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20
Q

Promoting health by identifying risk factors

A

Make sure you identify the patient

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21
Q

Ensure to diagnose both

A

actual and potential problems

22
Q

First level

A

Emergent, life threatening problems that cannot wait

23
Q

First level examples

A

Airway
Breathing
Circulation
Vital signs

24
Q

Second level

A

Require prompt intervention to stop further deterioration

25
Q

Second level examples

A
Mental status change
Acute pain
Acute urinary elimination
Untreated medical problems
abnormal lab values
risk of infection
risk of safety and security
26
Q

Third level

A

Important to patients health but can be addressed at a later time

27
Q

Third level examples

A

weight loss
Stoping smoking
Dietary management
Increasing activity

28
Q

Outcomes should be patient centered

A

You cannot make changes the patient is not ready for

ex: smoking/weight loss

29
Q

You should determine specific

A

interventions

30
Q

When evaluating you should

A

look at what you have done and correct thinking

31
Q

Determining a comprehensive plan/evaluation

A

come up with a plan and all faculty must collaborate to help

32
Q

Four factors of decision making

A
  • Best evidence from a critical review of literature
  • Clinical expertise and experience
  • Patient preference
  • Physical examination and assessment
33
Q

Complete health history

A

Health history
Physical exam
Information about diagnosis

Primary care, community health nurse, visiting nurse, administration to hospital

34
Q

Focused database

A
  • For limited or short term problem
  • Only for a certain area or body part
  • Used in times such as urgent care
35
Q

Follow up

A

Has the problem changed? is it getting better or worse?

Post surgery, checking blood pressure, medication check

36
Q

Emergency data base

A

Urgent and rapid collection of information while completing lifesaving measures

Taking vital signs while acting

37
Q

Holistic health

A

looking at the whole person

38
Q

Mind body and spirit

A

are independent and function as a whole

39
Q

Disease originates

A

from both internally and externally

40
Q

Individual and environment are…

A

open systems

41
Q

Each person is responsible for self-health and is active in their health care

A

You can’t make someone do something they dont want to do

42
Q

Health promotion and disease prevention are the core of nursing practice

A

Can we get you healthy and keep you that way?

43
Q

Lifestyle behaviors

A

Diet, exercise

44
Q

Culture and values

A

Some religion restricts type of care you can give

45
Q

Family and social roles

A

Who takes care of who?

46
Q

Self-care behaviors

A

keeping up with hygiene, ADL’s

47
Q

Job related stress

A

Can cause high blood pressure

48
Q

Developmental tasks

A

Developmental stages (where are you mentally, socially?)

49
Q

Failures and frustrations of life

A

what in life that makes you frustrated and feel like a failure.

How do you deal with it?

50
Q

Disease prevention

A

Counseling from primary care providers designed to change people’s unhealthy behaviors related to smoking, alcohol, and other drug use, lack of exercise, poor nutrition, injuries, and STI’s

51
Q

Health promotion

A

A set of positive acts that we can take

Teaching and helping consumer choose a healthier lifestyle
Education, leading by example