Health Assessment Chapter 1 Evidence Based Assessment

Front 1

Subjective Data

Back 1

what the person 'says' about himself or herself during the history.

Front 2

Objective Data

Back 2

What you as the health professional observe by inspecting, percussing, palpating, and auscultating.

Front 3

Database

Back 3

Objective, Subjective, and Lab Val data

Front 4

Diagnostic Reasoning

Back 4

the process of analyzing health data and drawing conclusions to identify diagnoses.

Front 5

What is the diagnostic process most novice examiners use and what steps does it involve?

Back 5

1. Attending to initially available cues
2. Formulating Diagnostic Hypothesis
3. Gathering data relative to the tentative hypothesis/es
4. Evaluating each hypothesis with the new data collected, thus arriving at the final diagnosis.

Front 6

What is a cue?

Back 6

A cue is a piece of information, sign or symptom, or a piece of laboratory data.

Front 7

What is a hypothesis?

Back 7

A hypothesis is a tentative explanation for a cue or a set of cues that can be used as a basis for further investigation.

Front 8

What is your first step in assessment?

Back 8

To gather data.

Front 9

What is your second step in assessment?

Back 9

Develop a preliminary list of significant signs and symptoms and all p/t health needs. (This is less formal than your final list and is in no particular order.)

Front 10

What should you do with data that appear to be casual or associated?

Back 10

Cluster them together.

Front 11

What is a novice nurse?

Back 11

A nurse with no experience with specified patient population.

Front 12

What is a competent nurse?

Back 12

2-3 years experience in the same clinical setting.

Front 13

What is a proficient nurse?

Back 13

+3 years in clinical setting

Front 14

What is an expert nurse?

Back 14

A nurse with extended amounts of experience that can arrive at a clinical judgement in one leap.

Front 15

Name some critical thinking skills.

Back 15

1. Identifying Assumptions
2. Identifying an organized and comprehensive approach
3. Validation
4. Distinguishing normal from abnormal
5. Making inferences
6. Clustering related cues
7. Distinguishing relevant from irrelevant
8. Recognizing inconsistencies
9. Identifying patterns.
10. Identifying missing information.
11. Promoting Health
12. Diagnosing actual and potential risk problems

Front 16

Define Nursing Diagnosis

Back 16

Clinical judgements made about a person's response to an actual or potential health state.

Front 17

What three categories are nursing diagnoses broken down into?

Back 17

1. Actual Diagnoses
2. Risk Diagnoses
3. Wellness Diagnoses

Front 18

What are Actual Diagnoses?

Back 18

Existing problems that are amenable to independent nursing interventions.

Front 19

What are Risk Diagnoses?

Back 19

Potential problems that an individual does not currently have but is particularly vulnerable to developing

Front 20

What are Wellness Diagnoses?

Back 20

Focus on strengths and reflect an individual's transition to a higher level of wellness.

Front 21

What is a medical diagnoses?

Back 21

A medical diagnosis is used to evaluate the etiology (cause) of disease.

Front 22

How do nursing diagnoses reflect upon medical diagnoses?

Back 22

A nursing diagnoses then analyzes the response that person is having to the actual or potential disease/health problem.

Front 23

Give an example of a medical diagnosis and a nursing diagnosis interacting.

Back 23

A p/t comes in and is assessed by nurse. Upon auscultation of the lungs, the nurse determines that lung sounds are diminished and that wheezing is present. This is BOTH a medical and a nursing clinical problem. BUT the physician listens to diagnose that cause (etiology) of the abnormal sounds, (asthma)->a MEDICAL DIAGNOSIS. The physician then orders specific drug treatment. The nurse then listens to detect abnormal sounds early, to monitor the p/t's response to treatment, and to initiate supportive measures and teaching.

Front 24

What does setting priorities mean?

Back 24

When there is more than one diagnosis.

Front 25

First level priority problems.

Back 25

Emergent, life threatening, and immediate. Such as establishing an airway or supportive breathing.

Front 26

What are second level priority problems?

Back 26

Those that are next in urgency-those requiring prompt intervention to forestall further deterioration. For example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risks of infection, risk to safety or security.

Front 27

What are third level priorities?

Back 27

Those that are important to the patients health, but can be addressed after more urgent health problems are addressed. Ex: Dysfunctional Family Process, Low Self Esteem *These are typically issues that people don't need to seek emergency room care for but they do*

Front 28

What is a way to remember first level priorities?

Back 28

Airway
Breathing
Cardiovascular
Vital sign concerns

Front 29

What are collaborative problems?

Back 29

Those in which the approach to treatment involves multiple disciplines. *ie: the problem affects more than one physiological system*

Front 30

What the four types of data collected all pertaining to different situations?

Back 30

Complete, Focused/Problem Centered, Follow-up, and Emergency

Front 31

Briefly explain what a complete (total) database is, and when you would use it.

Back 31

This includes a complete health history, and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. It yields first diagnoses. *This is completed is a primary care setting, and is the first health care professional situation to see the p/t. In an acute hospital setting, the complete database is also gathered after admission.

Front 32

Explain what a Focused or Problem Centered Database is?

Back 32

This is for a limited or short-term problem. Here you collect a "mini-data base." It is smaller in scope and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system. It is used in ALL settings, primary care, hospitals, or long-term.

Front 33

Explain what is a follow-up database?

Back 33

This type of data is used in any setting, and follows up all short-term and chronic health problems.

Front 34

Explain what an emergency database is.

Back 34

This calls for a rapid collection of data, often compiled concurrently with life saving measures.