Nurse 226

Front 1

______________ is the collection of data

Back 1

assesment

Front 2

______________ data (history) is what the PT says

Back 2

subjective

Front 3

______________ data is ALWAYS in "__"

Back 3

subjective

Front 4

_____ _____ data comes from a wife/spouse/parent

Back 4

subjective secondary

Front 5

_____ _____ data comes from the PT themselves

Back 5

primary subjective

Front 6

____ ______ data is what i assess as a nurse

Back 6

primary objective

Front 7

____ ______ data is what was previously noted via charts/lab results/ect.

Back 7

secondary objective

Front 8

______________ is the process of analyzing health data and drawing conclusions to identify diagnosis, it is based on the scientific method.

Back 8

diagnostic reasoning

Front 9

diagnostic reasoning has 4 main components:
1. A
2. F
3. G
4. E

Back 9

A - attending to initially available cues

F - formulating diagnostic hypothesis

G - gathering data to the tentative hypothesis

e - evaluating each hypothesis with the new data collected, this arriving at a final diagnosis

Front 10

a ______________ is a piece of information, a S/S, or a piece of labratory data.

Back 10

cue

Front 11

a ______________ is a tentative explanation for a cueor a set of cues that can be used as a basis for further inestigation

Back 11

hypothesis

Front 12

the ______________ is also based on the scientific method and includes 5 phases

1. A
2. D
3. P/O
4. I
5. E

Back 12

nursing process

A - assessment
D - diagnosis
P/O - planning/outcome
I - implementation
E - evaluation

Front 13

with ADPIE:

explain A -

C
R
I
H
P
F
C
R

Back 13

ASSESSMENT:

1 - collect data
2 - review the clinical record
3 - interview
4 - health history
5 - physical examination
6 - functional assessment
7 - consultation
8 - review of the literature

Front 14

with ADPIE:

explain D -

I
V
C
I
D

Back 14

DIAGNOSIS:

1 - INTERPRET DATA

identify clusters of cues
make inferences
2 - validate inferences
3 - compare clusters of cues with defining characteristics
4 - identify related factors
5 - document the diagnosis

Front 15

with ADPIE:

explain P/O -

(outcome identification)

I
I
R
I

(planning)

E
D
S
I
D

Back 15

OUTCOME:

1 - identify expected outcomes
2 - individualize to the person
3 - realistic and measurable
4 - include a time frame

(planning)

1 - establish priorities
2 - develop outcomes
3 - set time frames for outcomes
4 - identify interventions
5 - document plan of care

Front 16

with ADPIE:

explain I -

R
S
C
S
C
I
R
D

Back 16

IMPLEMENTATION:

1 - review the planned interventions
2 - schedule ad coordinate the persons total health care
3 - collaborate with toher team members
4 - supervise implementations of the care plan by delegatinf appropriate responsibilities
5 - counsel the person and significant others
6 - involve the person in healthcare
7 - refer individuals who require continuing care
8 - document the care provided

Front 17

with ADPIE:

explain E -

R
E
S
I
T
D

Back 17

EVALUATION:

1 - refer to established outcomes
2 - evaluate the individuals condition ans compare actual outcomes with expected outcomes
3 - summmarize the results of the evaluation
4 - identify reasons for the presons failiur, if indicated, to achieve expected outcomes stated in the plan of care
5 - document the evaluation of the persons achievement of outcomes and the medications, if any, in the plan of care

Front 18

critical thinking allows you to :

1. ________ critical data about your PT

2. make decisions about the PTs ________ and possible ________

3. ________each problem to decide which applies

4. decide on the most appropriate ________ for the situation

Back 18

1.analyze
2.problems & alternate
3.evaluate
4.intervention

Front 19

the ________ of western traditions views health as the absence of disease

Back 19

biomedical model

Front 20

________ views health as te mind, body, and spirit as interdependent and functioning as a whole within the environment.

Back 20

holistic

Front 21

________ data base (total health)

this inclusdes a complete health history and a full physical examination.

Back 21

complete

Front 22

________ or ________ data base:

this is for a limited or short term problem. a "mini" data base, smaller in scope and more focused is collected.

Back 22

episodic or problem-centered

Front 23

________ data base

the status of any identified problems should be evaluated at regular and appropriate intervals

Back 23

follow up

Front 24

________ data base

this calls for a rapid collection of the data, often compiled concurrently with lifesaving measures. diagnosis must be swift and sure.

Back 24

emergency

Front 25

the ________ is hte meeting between you and your PT. The goal is to record a complete health history.

Back 25

interview

Front 26

an interview collects ________ data.

Back 26

subjective

Front 27

the interview collects ________ data

Back 27

subjective

Front 28

a successful interview would mean the completion of these things:

G
E
T
B
B

Back 28

Gather complete and accurate data about the persons health state; including the description and chronology of any symptoms of illnesses

Establish rapport and trust so the person feels accepted and thus free to share all relavent data

Teach the person about the health state so that the peron can participate in identifying problems

Build rapport for a continuing theraputic relationship; this rapport facilitates future diagnosis, planning, and treatment

Begin teaching for health promotion and disease prevention

Front 29

a ________ consists of spoken and unspoken rules for ehavior

Back 29

contract

Front 30

a contracts terms include:

T/P
i/E
P
L
E
P
C
C

Back 30

time and place

introduction and explanation

purpose

length

expectations

presence of others

confidentiality

costs

Front 31

one will most likely be aware of ________ communication

Back 31

verbal (the words we speak, tone of vioce)

Front 32

body language,gestures,eye contact, foot tapping, ect. are examples of ________ communication

Back 32

nonverbal

Front 33

________ communication is most likely the truest reflection of your feelings

Back 33

nonverbal, because we are less aware we are doing it

Front 34

One must cultivate three innner factors for a successful interview:

L
E
A

Back 34

liking others
empathy
ability to listen

Front 35

________ is to recognize a persons feelings without criticism.

Back 35

empathy

Front 36

d

Back 36

fh

Front 37

the purpose of assessment is to make a _________ or _________

Back 37

judgment or diagnosis

Front 38

_________ is the starting point of every approach to clinical reasoning

Back 38

an organized assessment

Front 39

in the 70's and 80's, the nursing process was considered a clear, stepwise, linear approach that started with assessment and ended with evaluatio. Now we consider it to be a more _________,_________ process

Back 39

dynamic, interactive

Front 40

it takes about __ to __ years to delelop compentency in the clinical setting. The nurse will see actions in the contest of arching goals or daily plans for PTs

Back 40

2 to 3

Front 41

the _________ nurse has no experience with a specific patient population and uses rules to guide performance.

Back 41

novice