Evidence based assesment Flashcards
______ is the collection of data about the individuals health state
Assessment
———– Is What the patient says about himself/herself during history taking
Subjective data
What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination
Objective data
Subjective data, objective data, with patients record and laboratory studies is referred to as_______
database
from the _______ you make a clinical judgment or diagnosis about the individuals health state or response to actual or risk health problems and life processes, as well as diagnoses about higher levels of wellness.
database
The purpose of assessment is to make a ______ or ___________
judgment; diagnoses
___________ is the process of analyzing health data and drawing conclusions to identify diagnoses.
Diagnostic reasoning.
Novice examiners often use a diagnostic process involving hypothesis forming and deductive reasoning. This Hypothetico-deductive process has four major components. What are they?
- Attending to initially available cues
- formulating diagnostic hypotheses
- gathering data relative to the tentative hypotheses
4 evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis.
A ______ is a piece of information, a sign or symptom, or a piece of laboratory data.
cue
What is a hypothesis?
A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation
Validate the data you collect to make sure they are accurate… Why?
Identify missing pieces because it is an essential critical-thinking skill. Have an expert double check if you are unsure!
What are the six phases of the nursing process?
- assesment
- diagnosis
- outcome identification
- Planning
- Implementation
6 Evaluation.
Describe the differences between novice, competent, proficient, and expert nurses.
Novice- no experience and uses rules to guide performance
Competency- 2-3 years in similar clinical situations, in which you see actions in the context of arching goals or daily plans for patients
proficient nurses- understands a patient situation as a whole rather than as a list of tasks. You see long term goals
Expert- vault over the steps and arrive at a clinical judgment in one leap.
Nursing Process
Describe Assesment
collect data: review of the clinical record Health history Physical examination Functional assesment Review of the literature Use evidence-based assesment techniques Document relative data
Picture on page 3
Nursing Process:
Describe Diagnosis
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data Identify clusters or cues Make hypotheses Test hypotheses Derive diagnoses Validate diagnoses Document diagnoses
Page 3
Nursing Process:
Describe Outcome identification
Identify expecteed outcomes individualize to the person culturally appropriate realistic and measurable include a timeline
Nursing Process:
Describe Planning
Establish priorities Develop outcomes Set timelines for outcomes identify interventions integrate evidence based trends and research document plan of care
Nursing process:
Implementation
Implement in a safe and timely manner
use evidence-based interventions
collaborate with colleagues
use community resources
coordinate care delivery
provide health teaching and health promotion
document implementation and any modification
Nursing Process: Evaluation
- Progress toward outcomes
- conduct systematic ongoing, criterion based evaluation’
- include patient and significant others
- use ongoing assessment to revise diagnoses, outcomes, plan
- disseminate results to patient and family
What are the 17 critical thinking skills?
- Identifying assumptions
- Identifying an organized and comprehensive approach to assessment
- Validation
- Distinguishing normal from abnormal
- Making inferences
- Clustering related cues
- Distinguishing relevant from irrelevant
- Recognizing inconsistencies
- Identifying patterns
- Identifying missing information
- Promoting health
- diagnosing actual and potential (risk) problems
13.Setting priorities - Identifying patient-centered expected outcomes
- Determing specific interventions
- Evaluating and correcting thinking
17 determining a comprehensive plan
**Details on each skill on pages 4-6
_________ are clinical judgments about a persons response to an actual or potential health state
Nursing diagnoses
Actual diagnose- existing problems that are amenable to independent nursing interventions
Risk diagnoses- potential problems that an individual does not currently have but is particualrly vulnerable to developing
Wellnes diagnosis- focus on strengths and reflect an individuals transition to a higher level of wellness.
______ are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing
first-level priority problems
__________ next in urgency; requiring your prompt intervention to forestall further deterioration
Examples: mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.
Second-level priority problems
** Important to look at table on page 5
to asses for first level priority problems remember the “ABCs plus V”
What does the acronym refer to?
(A)irway problems
(B)reathing problems
(C)ardiac/circulation problems
(V)ital sign concerns
