WEEK1: Chapter 1 Key Points Critical Thinking and Evidence Informed Assessment Flashcards
ASSESSMENT
The Purpose: The database consists of subjective and objective data about a patient’s health, which are used to make a judgment or diagnosis based on data from various sources.
SUBJECTIVE DATA
Consists of information provided by the client.
OBJECTIVE DATA
Includes information obtained by the health care provider through physical assessment and observations.
DATABASE
The totality of information available about the patient: subjective data and objective data together with patient records, laboratory studies, and other diagnostic tests. From the database, you make a clinical judgment or diagnosis about the individual’s health state, health risks, response to health problems, life processes, and overall level of wellness.
DIAGNOSTIC REASONING
The process of analyzing health data and drawing conclusions to identify diagnoses. This process has four major components:
1.) Attending to initially available cues, which are pieces of information, signs, symptoms, or laboratory data
2.) Formulating diagnostic hypotheses, which are tentative explanations for a cue or a set of cues and can serve as a basis for further investigation
3.) Gathering data relative to the tentative hypotheses
4.) Evaluating each hypothesis with the new data collected, which leads to a final diagnosis
VALIDATING DATA
Ensures that the information you have collected is accurate and helps identify missing information; this process is essential to critical thinking.
The Nursing Process-Assessment
Collect Data
Organize Data
Validate Data
Document Data
This is where the Health Assessment Interview and Physical Examination fit in the nursing process! They provide the basis for information that will guide the rest of the process, including the creation of goals and nursing plans of care.
The Nursing Process-Diagnosis
-Analyzing Data
-Identifying health problems, risks, and strengths
-Formulating diagnostic statements (Nursing diagnoses)
The Nursing Process-Planning
-Prioritizing problems and diagnoses
-Formulating goals and health outcomes
-Identifying nursing interventions
The Nursing Process-Implementation
- Reassess the patient
-Determine the Patient’s need for assistance
-Implement Nursing Interventions
-Supervise delegated tasks/care
-Document nursing activities
The Nursing Process-Evaluation
-Collect data related to goals/outcomes
-Complete data with outcomes
-Relate nursing actions to patient goals/outcomes
-Draw conclusions about health/problem status
-Continue, modify, or end the patient’s plan of care
CRITICAL THINKING
The multidimensional thinking process is needed for sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been identified.
17 Critical Thinking Skills
- Identifying Assumptions
- Organized and Comprehensive Data Collection
- Validation of Data
- Distinguishing Normal from Abnormal
- Making Inferences
- Clustering Related Data
- Recognizing Inconsistencies
- Identifying Missing Information
- Promoting Health by Identifying Risk Factors
- Setting Priorities
- Identifying Patient-Centered Outcomes
- Determining Specific Interventions
- Evaluating and Correcting Thinking
- Developing a Comprehensive Plan
- Using Intuition
- Collaboration
- Reflection on Practice
Evidence-informed practice (EIP)
A systematic approach to practice and uses the best evidence, with one’s own clinical experience, and the patient’s values and preferences to make decisions about care and treatment and to improve outcomes.
Social determinants of health
The social, economic, and political conditions that shape the health of individuals, families, and communities.
Health promotion
A comprehensive social and political process that enables people to increase their control over the determinants of health and thereby improve their health.
The concept of health includes-
Health promotion and Disease prevention.
Relational Approach to Nursing Practice
It considers health and illness and their meanings as being shaped by social, cultural, family, historical, geographical, and the patient’s gender, age, ability, and other individual contexts.
The relational approach includes an examination of intrapersonal, interpersonal, and contextual dimensions.
Reflexivity
Central to a relational approach and involves a combination of observation, critical scrutiny, and conscious participation.
COMPLETE DATABASE (or total health database)
Includes a complete health history & findings from a full physical examination.
EPISODIC DATABASE (or problem-centered database)
It is used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database.
Follow-up Database
Evaluate the status of any identified problem at regular intervals to follow up on short-term or chronic health problems.
EMERGENCY DATABASE
It requires rapid data collection, often compiled while life-saving measures are occurring.
Other Considerations
-The frequency of assessment varies according to the patient’s age, sex, gender, ability, social context, and illness and wellness needs.
-Periodic preventative health examinations are recommended to prevent morbidity and mortality by identifying modifiable risk factors and early signs of treatable conditions.
