Chapter 1 Flashcards
Subjective data
What the person says themselves during the interview
Objective data
What you observe by inspection, percussing, palpating, and auscultating
Purpose of assessment
To make judgment or diagnosis
Data base
Subjective, objective, patients record, and lab studies
Diagnostic reasoning
The process of analyzing health data and drawing conclusions to identify diagnoses
Four components to diagnostic reasoning
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)
Cues
A piece of information, sign, symptom, or piece of lab data
Hypothesis
tentative explanation for a cue or set of cues that can be used as a basis for further investigation
Parts of the nursing process
Assessment Diagnosis Outcome identification Planning Implementation Evaluate
Critical thinking enables you to
- 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
Identify assumptions
Dont assume anything before you gather the facts
Validate
always validate information
Distinguish normal from abnormal
Ensure you know your patient’s normal
Identify and…
organize comprehensive approach to assessment
Make inferences
Drawing valid conclusions
Clustering related cues
Cluster alike information to sort the information
Distinguish
relevant from irrelevant
Recognize inconsistencies
Is the person’s story changing?
Identify…
Patterns and missing information
Promoting health by identifying risk factors
Make sure you identify the patient
Ensure to diagnose both
actual and potential problems
First level
Emergent, life threatening problems that cannot wait
First level examples
Airway
Breathing
Circulation
Vital signs
Second level
Require prompt intervention to stop further deterioration
Second level examples
Mental status change Acute pain Acute urinary elimination Untreated medical problems abnormal lab values risk of infection risk of safety and security
Third level
Important to patients health but can be addressed at a later time
Third level examples
weight loss
Stoping smoking
Dietary management
Increasing activity
Outcomes should be patient centered
You cannot make changes the patient is not ready for
ex: smoking/weight loss
You should determine specific
interventions
When evaluating you should
look at what you have done and correct thinking
Determining a comprehensive plan/evaluation
come up with a plan and all faculty must collaborate to help
Four factors of decision making
- Best evidence from a critical review of literature
- Clinical expertise and experience
- Patient preference
- Physical examination and assessment
Complete health history
Health history
Physical exam
Information about diagnosis
Primary care, community health nurse, visiting nurse, administration to hospital
Focused database
- For limited or short term problem
- Only for a certain area or body part
- Used in times such as urgent care
Follow up
Has the problem changed? is it getting better or worse?
Post surgery, checking blood pressure, medication check
Emergency data base
Urgent and rapid collection of information while completing lifesaving measures
Taking vital signs while acting
Holistic health
looking at the whole person
Mind body and spirit
are independent and function as a whole
Disease originates
from both internally and externally
Individual and environment are…
open systems
Each person is responsible for self-health and is active in their health care
You can’t make someone do something they dont want to do
Health promotion and disease prevention are the core of nursing practice
Can we get you healthy and keep you that way?
Lifestyle behaviors
Diet, exercise
Culture and values
Some religion restricts type of care you can give
Family and social roles
Who takes care of who?
Self-care behaviors
keeping up with hygiene, ADL’s
Job related stress
Can cause high blood pressure
Developmental tasks
Developmental stages (where are you mentally, socially?)
Failures and frustrations of life
what in life that makes you frustrated and feel like a failure.
How do you deal with it?
Disease prevention
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
Health promotion
A set of positive acts that we can take
Teaching and helping consumer choose a healthier lifestyle
Education, leading by example
