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
what does evaluation do
did we reach the goals
why is important to preform a consultation when collecting data
to see if there is a reason or trend with abnormal finding
what are first level priorities
airway
breathing
circulation
what are second level priorities
acute pain
change in mental status
infection
what are third level priorities
lack of knowledge
family coping
activity
rest
what are clusters
groups of cues of abnormal values to help make a diagnosis
how would we validate not being able to feel a pulse on a patient who is fully aware
use a doppler to feel
use stethoscope to listen to apical pulse
how would we validate a patient who looks out of breath
use a pulse ox to determine oxygen saturation
is validating information always a numerical value
no
complete (total health) database
focus on all body systems
Emergency database (or problem centered database)
focus only on one system
follow up data base
made after a diagnosis
what is EBP
systematic approach to practice that emphasizes the use of best evidence
5 steps to evidence based practice
ask the clinical question
acquire sources of evidence
appraise and synthesize evidence
apply relevant evidence in practice
assess the outcomes
validation of data entails
1. distinguishing normal from abnormal
2. making interferences
3. using an organized and comprehensive approach
4. checking the accuracy and reliability of the data
- checking the accuracy and reliability of the data
which critical thinking skill helps the nurse to see relationships among the data
1. validation
2. clustering related cues
3. identifying gaps in data
4. distinguishing relevant from irrelevant
- clustering related cues
an example of subjective data is
1. decreased range of motion
2. crepitation in the left knee joint
3. left knee has been swollen and hot for the past 3 days
4. arthritis
- left knee has been swollen and hot for the past 3 days (this could be objective if the 3 days was not said since hot and swollen is objective data)
which of the following is considered an example of objective data
1. alert and oriented
2. dizziness
3. an earache
4. sore throat
- alert and oriented
(cannot assess dizziness, earache, sore throat, cannot assess pain)
first level priority AKA
life threatening
second level priority AKA
urgent
third level priority AKA
can wait
what priority would be a BP of 60/40
first level priority
what priority would be difficulty breathing, pulse oximeter 88 on room air
first level priority
what priority would be hunger and thirst
third priority
what priority is anxiety
second priority (could be first if patient is having extreme anxiety attack with hyperventilating)
what priority would a temp of 103 F
second priority
an adult with a temp of 103 in an adult would be a second priority but if that infant had that same temp what would be the priority
first priority
