Ch. 1

Front 1

Assessment

Back 1

The collection of data about the individual's health state. The purpose of _____ is to make a judgment or diagnosis.

Front 2

Subjective data

Back 2

what the person says about himself/herself during history taking

Front 3

Objective data

Back 3

what you say as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination.

Front 4

Database

Back 4

Subjective data, objective data, and the patient's record and laboratory studies form the _____

Front 5

Diagnostic reasoning

Back 5

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

Front 6

Hypothetico-deductive process

Back 6

1. Attending to initially available cues

2. Formulating diagnostic hypotheses

3. Gathering data relative to the tentative hypotheses

4. Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis

Front 7

Cue

Back 7

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

Front 8

Hypothesis

Back 8

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

Front 9

Nursing process

Back 9

The standards in nursing is traditionally termed the _________. It includes six phases:

1. Assessment

2. Diagnosis

3. Outcome identification

4. Planning

5. Implementation

6. Evaluation

Front 10

First-level priority problems:

ABCs plus V

Back 10

Priority problems that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.

Airway problems

Breathing problems

Cardiac/Circulation problems

Vital sign concerns

Front 11

Second-level priority problems

Back 11

Priority problems that are next in urgency- those requiring your prompt intervention to forestall further deterioration ex: mental status change, acute pain, acute urinary elimination problems, abnormal lab values, risk of infection, safety, or security, untreated medical problems, etc.

Front 12

Third-level priority problems

Back 12

Priority problems that are important to the patient's health but can be addressed after more urgent health problems are addressed. Interventions to treat these problems are more long term, and the response to treatment in expected to take more time.

Ex: problems with lack of knowledge, activity, rest, family coping

Front 13

Collaborative Problems

Back 13

Problems in which the approach to treatment involves multiple disciplines. These problems are certain physiologic conditions in which nurses have the primary responsibility to diagnose the onset and monitor the changes in status.

Front 14

Final steps to the critical-thinking process:

Back 14

Evaluation and planning

Front 15

Evidence-based practice (EBP)

Back 15

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

Front 16

Four factors in clinical decision making

Back 16

1. The best evidence from a critical review of research literature

2. The patient's own preferences

3. The clinician's own experience and expertise

4. Physical examination and assessment

Front 17

Four types of databases

Back 17

1. Complete (Total Health) Database

2. Focused or Problem-Centered Database

3. Follow-Up Database

4. Emergency Database

Front 18

Complete (Total Health) Database

Back 18

A database that includes a complete health history and a full physical examination. It must screen for pathology and determine the ways people respond to that pathology or to any health problem.

Front 19

Focused or Problem-Centered Database

Back 19

A database that is for a limited or short-term problem. Here you collect a "mini" database, smaller in scope and more targeted that the complete database. It concerns mainly one problem, one cue complex, or one body system.

Front 20

Follow-Up Database

Back 20

This type of database is used in all settings to follow up both short-term and chronic health problems. The status of any identified problems should be evaluated at regular and appropriate intervals.

Front 21

Emergency Database

Back 21

This is an urgent, rapid collection of crucial information and often is compiled concurrently with lifesaving measures. Diagnosis must be swift and sure. Once the person has been stabilized, a complete database can be compiled.

Front 22

Holistic health

Back 22

Consideration of the whole person is the essence of _____________. This type of health views the mind, body, and spirit as interdependent and functioning as a whole within the environment.

Front 23

The Guide to Clinical Preventive Services

Back 23

A positive approach to health assessment and risk reduction