jarvis chapter 1 Flashcards
Subjective Data
what the client says about himself or herself during the history taking/appointment
Objective Data
What you as the health care provider observe by inspecting, percussing, palpating, and auscultating during the physical examination
Data Base
Combination of the patient’s record, your objective data, the patient’s subjective data, and laboratory studies
Diagnostic Reasoning
the process of analyzing health data and drawing conclusions to identify diagnoses
there are four major components:
- attending to initially available cues
- formulating diagnostic hypotheses
- gathering data relative to tentative hypotheses
- evaluating each hypothesis with the new data collected and thus arriving at a final diagnosis.
Hypothesis
Tentative explanation for a cue or a set of cues that can be used as the basis for further investigatioon
Cue
a piece of information, a sign or symptom, or a piece of laboratory data
Nursing Process
ADPIE assessment diagnosis planning (outcomes and interventions) implementation evaluation
Assessment
establishment of a database
cluster data, validate it and document it!
data includes objective, subjective, laboratory, and secondary sources like literature and patient records.
Diagnosis
Nursing diagnosis is a diagnostic label married to related factors
there are five types of diagnosis:
actual dx (existing conditions)
risk dx
health promotion dx
wellness dx (describing how wellness can be enhanced)
syndrome dx (based on grouping of signs and symptoms)
Nursing Diagnosis
clinical judgments about a person’s response to an actual or potential health state and identification of their health concerns, risks, and goals in response to the nurse’s analysis of assessment data.
planning
planning of PATIENT CENTERED goals, interventions and outcomes
combine a VERB with a CONDITION and CRITERION
priority setting
goals in care plans should be:
patient-centered singular observable measurable time limited mutual realistic
Evidence-Informed Practice
A systematic approach to practice that emphasizes the use of best evidence in combination with clinician experience and patient preferences/values
Evidence-Based Practice
Applying current best-practice knowledge to individual patients
biomedical model of health
western tradition of health as the absence of disease
