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29 Cards in this Set
- Front
- Back
what the person SAYS about himself/herself during history taking
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subjective data
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what you as the health professional OBSERVE by inspecting, percussing, palpating, and auscultating during the physical exam
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objective data
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subjective data, objective data, the patient's record and laboratory studies
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data base
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from the ____________, you make a clinical judgment or diagnosis about the individual's health state or response to actual or risk health problems and life processes, as well as diagnoses about higher levels of wellness
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data base
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the purpose of assessment
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to make a judgment or diagnosis
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the starting point of every approach to clinical reasoning
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an organized assessment
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the process of analyzing health data and drawing conclusions to identify diagnoses, (based on the scientific method)
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diagnostic reasoning
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what are the 4 major components of diagnostic reasoning?
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1. attending to initially available clues
2. formulating diagnostic hypotheses 3. gathering data relative to the tentative hypotheses 4. evaluating each hypothesis the new data collected, thus arriving at a final diagnosis |
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a piece of information, a sign or symptom, or a piece of laboratory data
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cue
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a tentative explanation for a cue or a set of cues that can be used as the basis for further investigation
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hypothesis
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diagnostic hypotheses are activated _________ in the reasoning process
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very early
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also based on the scientific method, _____________ includes 6 phases
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the nursing process
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what are the 6 phases of the nursing process?
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1. assessment
2. diagnosis 3. outcome identification 4. planning 5. implementation 6. evaluation |
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collection of data about the individual's health state
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assessment
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levels of nursing
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1. novice
2. competent 3. proficient 4. expert |
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the ________ nurse has no experience with a specified patient population and uses rules to guide performance
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novice
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the _________ nurse sees actions in the context of arching goals or daily plans for patients
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competent
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the _______ nurse understands a patient situation as a whole rather than as a list of tasks. this nurse sees long-term goals for the patient.
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proficient
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the __________ nurse vaults over the steps and arrives at a clinical judgment in one leap
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expert
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true or false: a nursing model is used along with, not in place of, a medical model
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true
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all conceptual (nursing) models deal with the same 4 concepts. what are they?
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1. human beings
2. environment and society 3. health and illness 4. nursing |
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clinical judgments about a person's response to an actual or potential health state
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nursing diagnoses
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existing problems that are amenable to independent nursing interventions
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actual diagnoses
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potential problems that an individual does not currently have but is particularly vulnerable to developing
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risk diagnoses
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focus on strengths and reflect an individual's transition to a higher level of wellness
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wellness diagnoses
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views health as the absence of disease, focuses on the diagnosis and treatment of pathogens and the curing of disease
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biomedical model
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a dynamic process, a move toward optimal funcioning
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wellness
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consideration of the whole person, views the mind, body, and spirit as interdependent and functioning as a whole within the environment
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holistic health
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what are the four types of data?
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1. complete (total health) data base
2. episodic or problem centered data base 3. follow-up data base 4. emergency data base |