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Nurse Assessment > Evidenced Based Assessment > Flashcards

Evidenced Based Assessment Flashcards

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1
Q

What is the Nursing Process in order?

A

ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation

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2
Q

Why is doing an assessment so important?

A

It is fundamental to the remainder of the process. All healthcare diagnoses, decisions, and treatments are based on the data gathered during assessment.

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3
Q

Where do we collect data from during assessment?

A

Review of the clinical record
Interviewing the patient
health history (from convo)
Physical exam
Functional Assessment (how they are functioning in daily life)
Consultation
Review of the literature

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4
Q

What is subjective data?

A

what the patient tells you.

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5
Q

what kind of data is pain?

A

Subjective data.

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6
Q

What is objective data?

A

what you assess through physical and mental assessment.

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7
Q

what kind of data is this?
Temperature: 37.4
Pulse: 64
Respirations: 15
SPO2: 97%

A

Objective data

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8
Q

What kind of data is laboratory data?

A

Objective Data
Ex.The patients medical record

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9
Q

What is the purpose of assessment?

A

To formulate a a clinical judgement or diagnosis about the patient’s health state

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10
Q

What kind of data do we need to formulate a diagnosis?

A

subjective data
objective data
patient’s record
laboratory studies
Review of literature

Think of it as an equation.

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11
Q

What is factually based data and evidenced-based data free of?

A

Free of assumptions and biases

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12
Q

What is diagnostic reasoning?

A

Process of analyzing data and drawing conclusions to identify diagnoses

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13
Q

What are cues?

A

pieces of information gathered that show an abnormal sign or altered health state.

These clues could also be pieces of information gathered leading to normal findings

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14
Q

What are clusters?

A

The grouping together of cues.

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15
Q

What are the 3 things to do when interpreting data collected?

A

Cluster or group together cues
look for patterns
make inferences

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16
Q

What should you do with data collected, especially abnormal data?

A

Validate it. Always.

17
Q

What are the components of diagnostic reasoning?

A

Attend to initially available cues (pieces of information)
Formulate diagnostic hypotheses (tentative explanation of cues)
Gather relevant data
evaluate each hypothesis with ongoing data collection.
*serves as a basis for ongoing investigation

18
Q

What is required for sound diagnostic reasoning and clinical judgment?

A

Critical thinking

19
Q

What are the three dimensions of critical thinking

A

Theory and Experiential Knowledge to perform the nursing process

commitment to learning to think critically

psychomotor and manual skill development

20
Q

What are first priority?

A

ABC

Airway
Breathing
Circulation

21
Q

What are second level priorities?

A

Acute pain

Change in mental status

Infection

22
Q

What are third level priorities?

A

Are important to patient’s health but can be addressed after more urgent problems.

Lack of knowledge
Family coping
activity
rest

23
Q

What are the four types of databases?

A

Complete (total health)
episodic or problem-centered
Follow-up
Emergency

24
Q

What is a complete (total health) database?

A

A full examination of every body system; head-to-toe assessment.

25
Q

What is episodic (problem-centered) data base?

A

Focuses on only one body system that is having a problem.

26
Q

What is follow-up data?

A

Following up on a health issue that was previously addressed or treated.

27
Q

What is an emergency database?

A

life or death assessment. Focused especially on one body system to prevent fatal outcomes.

ex. A patient comes in with an open hemorrhage of the femoral artery. Focused on stopping the bleeding and nothing else.

28
Q

What is evidenced based assessment?

A

Rooted in the belief that all patients deserve to be treated with the most current and best-practice techniques.

29
Q

What is evidence-based practice?

A

A systematic approach to practice that emphasizes the use of best evidence.

30
Q

What does evidence-based practice involve?

A

Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences.

31
Q

What are the 5 steps to evidence-based practice? (A’s)

A

Ask the clinical question
Acquire sources of evidence
appraise and synthesize evidence
apply relevant evidence in practice
Assess the outcomes

32
Q
A

Nurse Assessment (6 decks)

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