Unit 1: assessment of the whole person Flashcards
Diagnostic Reasoning
process of analyzing heath data and drawing conclusions to identify diagnoses.
1) attend to initial cues
2) formulate diagnostic hypothesis
3) gather data relative to tentative hypothesis
4) evaluate each hypothesis with new data collected – > arriving at final diagnosis
Nursing process
1) assessment
2) diagnosis
3) outcome identification
4) planning
5) implementation
6) evaluation
assessment
Collect Data: review clinical record, health history, physical exam, functional assessment, risk assessment, review of literature, evidence-based assessment techniques, document relevant data
diagnosis
- Compare clinical findings with normal and abnormal variation and developmental events
- interpret data: identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses
- validate diagnoses
- document diagnoses
outcome identification/planning
- identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include timeframe
- establish priorities
- develop outcomes
- identify interventions
- integrate evidence based trends and research
- document plan of care
implementation
- implement in safe and timely manner
- evidence-based interventions
- collaborate with colleagues
- use community resources
- coordinate care delivery
- provide health teaching and promotion
- document implementation and any modification
Evaluation
- progress toward outcomes
- conduct systematic, ongoing, criterion-based evaluation
- include patient and significant others
- use ongoing assessment to revise diagnoses, outcomes, plan
- disseminate results to patient and family
Critical Thinking Skills
1) identifying assumptions: make sure you are careful to not automatically see something as a fact if it isn’t, don’t take certain information for granted
2) identifying an organized and comprehensive approach: PRIORITIES
3) Validation: check accuracy and reliability of data collected. corroborate with family members, social worker
4) distinguishing normal from abnormal: learn this through experience and gained knowledge
5) making inferences: hypothesis. interpret data and make hypothesis.
6) clustering related cues: find relationships in data
7) distinguishing relevant from irrelevant: full health assessment then take what is actually important
8) recognizing inconsistencies: conflicintg information given versus your findings, etc.
9) identifying patterns: helps fill in the whole pictures and fills in missing information
10) identify missing information: gaps in data, need for more data prior to diagnosis
11) promoting health: identify risk factors,
12) diagnosising actual and potential (risk) problems: see nursing diagnoses
13) setting priorities: when there is more than one diagnosis.
14) identifying patient-centered expected outcomes: timeframe and specific results you are looking for
15) determining specific interventions: prevent, manage or resolve health problems
16) evaluating and correcting thinking: successful interventions, outcomes consistent with goals?
17) determining comprehensive plan: revised plan of care for future
nursing diagnoses
clinical judgements about a person’s response to an actual or potential health state.
1) ACTUAL diagnoses: existing problems that are amenable to independent nursing interventions
2) RISK diagnoses: potential problems that an individual does not currently have but is particularly vulnerable to developing
3) WELLNESS diagnoses: focus on strengths and transitions to an individual’s higher level of wellness.
types of priorities
1) first-level priorities: emergent, life-threatening, immediate
A airway problems
B breathing problems
C cardiac/circulation problems
V vital sign concerns
2) second-level priorities: next in urgency, prompt intervention to forestall further deterioration (mental status change, acute pain, risk of infection)
3) Third-level priorities: important to patient’s health but can be addressed later (chronic low self esteem, dysfunctional family process)
**Collaborative problems–> approach to treatment involves many disciplines (exp: alcoholic)
setting priorities
1) make a list of current meds, medical problems, allergies, reasons for seeking care.
2) determine the relationships among the problems
4 types of data
1) complete (total health) database
complete health history and full physical exam
2) focused/problem-centered database
for a limited or short term problem
3) follow up database
check the status of any identified problems
4) emergency database
rapid collection of data about an individual’s health state
holistic health
views the mind, body, and spirit as interdependent and functioning as a whole within the environment.
- includes culture and values, family and social roles, self-care behaviors, job-related stress, developmental tasks, and failures and frustrations.
- health promotion and disease prevention
culture and genetics
34% of total us population is emerging minority
- hispanics 24.3%, blacks 13.2%, asian/pacific islander 8.9% and american indian 0.8%
- largest growing pop is hispanic
- 2nd largest is asian, then blacks, american indians, alaska natives, and native hawaiians and islanders.
- median age in 2007 was 36.6, 1/4 younger than 18
- hispanic median age = 27, blacks 31, amican indian and alaskans = 30, hawaiin and islanders = 30 ==> all cose to 1/2 pop under 18
- white median ages are between 36 and 40
legal resident
granted lawful permanent residence
natualization
the conferring, by any means, of citizenship upon a person after birth
non-immigrant
an alien who seeks temporary entry to the US for a specific purpose
parolee
an alien, allowed to the US for urgent humanitarian reasons or when their entry is significant to the public’s benefit
permanent resident alien
alien admitted to the us as lawful permanent resident
