Physical Examination And Health Assessment Ch.1

Front 1

Assessment

Back 1

Collection of data about an individual's health state (physical, cognitive,psychosocial, behavioral, spiritual)

Front 2

Assessment Database

Back 2

includes: subjective data, objective data, patients record, laboratory studies

Front 3

subjective data(health history)

Back 3

what patients says about himself or herself during history taking

Front 4

objective data(health assessment)

Back 4

observed when inspecting, percussing, palpating, and auscultating patient during physical examination

Front 5

Diagnostic Reasoning

Back 5

the process of analyzing health data and drawing conclusions to identify the diagnosis

Front 6

4 Steps in Diagnostic reasoning

Back 6

1)attend to initially available cues

cue: piece of information, sign, symptom, or piece of laboratory data

2)formulate diagnostic hypotheses

hypotheses: tentative explanation for cues used as a basis for further investigation

3)Gather data relative to tentative hypotheses

4) evaluate each hypothesis with new data collected to arrive at final diagnosis.

Front 7

Levels of Nursing: Novice

Back 7

No experience

Uses rules to guide performance

Front 8

Levels of Nursing: Competency

Back 8

2-3 years

Able to use pt goals/plans to provide care

Front 9

Level of Nursing: Proficiency

Back 9

sees the pt as a "whole" rather than a list of tasks

Front 10

Levels of Nursing: Expert

Back 10

Uses clinical judgment

Front 11

Identify assumptions

Back 11

recognize information taken for granted or fact without evidence for it

Front 12

Organized approach

Back 12

use an organized, systematic assessment format

Front 13

Validation

Back 13

check and corroborate accuracy and reliability data

Front 14

Normal and abnormal

Back 14

distinguish when identifying signs and symptoms

Front 15

Inferences or drawing valid conclusions

Back 15

interpreting data and deriving correct conclusions

Front 16

Clustering related cues

Back 16

assists seeing relationships among data

Front 17

Relavance

Back 17

look at clusters of data and consider which are important for health problem

Front 18

Inconsistencies

Back 18

recognize subjective data at odds with objective data

Front 19

identify patterns

Back 19

helps to see whole picture and discover missing pieces of information

Front 20

Missing information

Back 20

identity gaps in data or need for more specific interviewing or laboratory data to make diagnosis

Front 21

Health promotion

Back 21

identify and manage know risk factors for individual's age group and cultural status

Front 22

Risk diagnosis

Back 22

identify actual and potential risks from full list of both medical and nursing assessment data

Front 23

Set priorities

Back 23

first-level priority problems: emergent, life threatening, and immediate

second-level priority problems: next in urgency

third-level priority problems: important to

patient's health but can be addressed after more urgent problems are addressed

Front 24

collaborative problem

Back 24

when approach to treatment involves multiple discipline

Front 25

Outcomes

Back 25

determine patient-centered expected outcomes

specific, measurable, results expected to improve person's problem after treatment

outcome statements include specific time frame

Front 26

Interventions

Back 26

determine specific interventions that will achieve expected outcomes

interventions aim to prevent, manage, or resolve health problems

this is the health care plan

Front 27

Evaluation and corrective thinking

Back 27

analyze outcomes and apply them for evaluation

Front 28

Evidence Based Practice (EBP)

Back 28

The systemic approach to practice that emphasizes the use of best evidence (research) in combination with the clinician's experience, as well as the patient's preferences and values, to make decisions about care and treatment

Front 29

Collecting four types of data: Complete (Total Health) Database

Back 29

includes complete health history and full physical examination

Front 30

Collecting data type: Focused or problem-centered database

Back 30

for limited or short term problems

concern mainly one problem.

Collect in: Hospitals, primary care, long-term care

Front 31

Collecting data: Follow-up database

Back 31

status of all identified problems should be evaluated at regular and appropriate intervals.

Note changes that have occurred.

Evaluate whether problem is getting better or worse. collect in all settings

Front 32

Collecting data: Emergency database

Back 32

rapid collection of data,often compiled concurrently with lifesaving measure

diagnosis must be swift and sure

Front 33

Holistic Health

Back 33

view the mind, body, and spirit as interdependent and health depends on all these factors working together.

Holistic model of care must include culture.

Front 34

Heritage assessment

Back 34

gathers meaningful data and intervene with culturally sensitive and appropriate care.