Week 1 Flashcards
what the person says about themselves during history taking
Subjective Data
what you as the health care provider observe by inspecting, percussing, palpitating, and osculating during the physical examination
Objective Data
subjective data, objective data, the patient’s record, laboratory studies, and other diagnostic tests form this
Database
the process of analyzing health data and drawing conclusions to identify diagnoses
Diagnostic Reasoning
A) attending to initially available cues,
B) formulating diagnostic hypotheses
C) gather data relative to tentative hypotheses and
D) evaluation each hypothesis with the new data collected, thus arriving at the final diagnosis
The 4 steps of diagnostic reasoning
a systematic method of planning and providing patient care organized around a series of phases that integrate evidence-informed practice and critical thinking
Nursing Process
a) assessment, b) nursing diagnosis, c) planning, d) implementation, and e) evaluation
5 Steps of the Nursing Process
Collect data related to outcomes
Complete data without outcomes
Relate nursing actions to patient goals/outcomoes
Draw conclusions about problem status
Continue, modify, or end the patient’s care plan
Evaluation
Collect data
Organize data
Validate data
Document data
Assessment
Analyze data
Identify health problems, risks, and strengths
Formulate diagnostic statements
Nursing Diagnosis
Prioritize problems and diagnoses
Formulate goals and desired health outcomes
Identify nursing interventions
Planning
Reassess the patient
Determine the nurse’s need for assistance
Implement nursing interventions
Supervise delegated care
Document nursing activities
Implementation
registered nurses who typically have a masters degree and have advanced education in health assessment and the diagnosis and management of illness and injuries, including the ability to order diagnostic tests and prescribe medications
Nurse Practitioner
Airway problems
Breathing problems
Cardiac problems
Vital sign concerns
Exception: with CPR resuscitation for cardiac arrest
First priority ABC’s
problems that are emergencies, life-threatening, and immediate, such as establishing an airway or supporting breathing
First-level priority problem
health care extends beyond treating disease to include secondary and primary preventions, with emphasis on changing behaviours and lifestyles
Behaviour model
are recommended according to age, risk and people’s particular needs to provide preventative counselling and screening test proven to be of benefit and are identified as particularly useful for people older than 65
Periodic preventative examinations
problems that are important to the patient’s health but can be addressed after more urgent health problems are addressed. Referrals and interventions for these problems are lengthier, response to treatment takes more time
Third-level problem
problems in which the approach to treatment involves multiple disciplines, and nurses often have the primary responsibility to diagnose the onset and monitor the changes in status
Collaborative problem
problems that are next in urgency: those necessitating the prompt intervention to forestall further deterioration, such as mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety and security
Second-level priority problem
Lifelong problem-solving approach to clinical decision making that involves the conscientious use of the best available evidence with one’s own clinical expertise and patient values and preferences to improve outcomes for individuals, groups, and community systems
Evidence-informed practice
the predominant model of the Canadian healthcare system, health is the absence of disease
Biomedical model
health care extends beyond treating disease to include secondary and primary preventions, with emphasis on changing behaviours and lifestyles
Behavioural model
incorperates sociological and environmental aspects in addition to the biomedical and behavioural ones
Socio-enviromental model
social, economic, and political conditions that shape the health of individuals, families, and communities
Social determinants of health
comprehensive social and political process of enabling people to increase control over the determinants of health and thereby improve their health
Health promotion
