Evidence Based Assessment (Chapter 1) Flashcards
what is data collection
the collection of data about an individuals health state
what is required for sound diagnostic reasoning and clinical judgment
critical thinking
what is the purpose of an assessment
to make a judgment or diagnosis
what type of diagnosis do nurses make
nursing diagnosis (not medical)
what are cues
pieces of data that help the nurse make diagnosis
what form the database
subjective data
objective data
patients record
lab studies
subjective data
what the patient tells you during interaction
objective data
info from assessment
what type of data would this be
- 76 bpm
- 3.8 Potassium
- 129 Sodium
objective
what type of data would this be
- “I have not been able to put weight on my left leg for 4 days now”
subjective
what type of data is typically pain
subjective
what type of data would this be
- double mastectomy (found in chart)
objective
what are the 3 dimensions of critical thinking
theory and experiential knowledge to preform that nursing process
commitment to learning to think critically
psychomotor and manual skill development
what is always the first step of the nursing process
assessment
why is assessment always the first step of the nursing process
build on data we collect
steps of nursing process in order
assessment
diagnosis
outcome identification
planning
implementation
evaluation
what do outcome identification and planning do
the outcome we want to see happen
goals
what does implementation do
things to implement or take away to reach goal