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