Evidence Based Assessment (Chapter 1) Flashcards

1
Q

what is data collection

A

the collection of data about an individuals health state

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2
Q

what is required for sound diagnostic reasoning and clinical judgment

A

critical thinking

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3
Q

what is the purpose of an assessment

A

to make a judgment or diagnosis

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4
Q

what type of diagnosis do nurses make

A

nursing diagnosis (not medical)

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5
Q

what are cues

A

pieces of data that help the nurse make diagnosis

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6
Q

what form the database

A

subjective data
objective data
patients record
lab studies

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7
Q

subjective data

A

what the patient tells you during interaction

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8
Q

objective data

A

info from assessment

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9
Q

what type of data would this be
- 76 bpm
- 3.8 Potassium
- 129 Sodium

A

objective

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10
Q

what type of data would this be
- “I have not been able to put weight on my left leg for 4 days now”

A

subjective

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11
Q

what type of data is typically pain

A

subjective

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12
Q

what type of data would this be
- double mastectomy (found in chart)

A

objective

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13
Q

what are the 3 dimensions of critical thinking

A

theory and experiential knowledge to preform that nursing process
commitment to learning to think critically
psychomotor and manual skill development

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14
Q

what is always the first step of the nursing process

A

assessment

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15
Q

why is assessment always the first step of the nursing process

A

build on data we collect

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16
Q

steps of nursing process in order

A

assessment
diagnosis
outcome identification
planning
implementation
evaluation

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17
Q

what do outcome identification and planning do

A

the outcome we want to see happen
goals

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18
Q

what does implementation do

A

things to implement or take away to reach goal

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19
Q

what does evaluation do

A

did we reach the goals

20
Q

why is important to preform a consultation when collecting data

A

to see if there is a reason or trend with abnormal finding

21
Q

what are first level priorities

A

airway
breathing
circulation

22
Q

what are second level priorities

A

acute pain
change in mental status
infection

23
Q

what are third level priorities

A

lack of knowledge
family coping
activity
rest

24
Q

what are clusters

A

groups of cues of abnormal values to help make a diagnosis

25
Q

how would we validate not being able to feel a pulse on a patient who is fully aware

A

use a doppler to feel
use stethoscope to listen to apical pulse

26
Q

how would we validate a patient who looks out of breath

A

use a pulse ox to determine oxygen saturation

27
Q

is validating information always a numerical value

A

no

28
Q

complete (total health) database

A

focus on all body systems

29
Q

Emergency database (or problem centered database)

A

focus only on one system

30
Q

follow up data base

A

made after a diagnosis

31
Q

what is EBP

A

systematic approach to practice that emphasizes the use of best evidence

32
Q

5 steps to evidence based practice

A

ask the clinical question
acquire sources of evidence
appraise and synthesize evidence
apply relevant evidence in practice
assess the outcomes

33
Q

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

A
  1. checking the accuracy and reliability of the data
34
Q

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

A
  1. clustering related cues
35
Q

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

A
  1. 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)
36
Q

which of the following is considered an example of objective data
1. alert and oriented
2. dizziness
3. an earache
4. sore throat

A
  1. alert and oriented
    (cannot assess dizziness, earache, sore throat, cannot assess pain)
37
Q

first level priority AKA

A

life threatening

38
Q

second level priority AKA

A

urgent

39
Q

third level priority AKA

A

can wait

40
Q

what priority would be a BP of 60/40

A

first level priority

41
Q

what priority would be difficulty breathing, pulse oximeter 88 on room air

A

first level priority

42
Q

what priority would be hunger and thirst

A

third priority

43
Q

what priority is anxiety

A

second priority (could be first if patient is having extreme anxiety attack with hyperventilating)

44
Q

what priority would a temp of 103 F

A

second priority

45
Q

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

A

first priority