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18 Cards in this Set
- Front
- Back
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What does OLDCARTS stand for?
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Onset
Location Duration Characteristics Aggravating/associated factor Relieving factors Treatments thus far Significance of symptoms |
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When do you use "old carts"?
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whenever a patient reports a symptom, it needs to be explored
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What does IPPA stand for?
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Inspection
Palpation Percussion Ausculation -perform in that order |
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What is an assessment?
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collection of data about the individuals health staate
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Compare subjective and objective data.
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subjective data is what the person says about themselves during history taking; objective data is data you observe by inspecting, percussing, palpating, and ausculating during the physical exam
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What elements form the database?
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-patients record
-lab studies -subjective data (in pt. history) -objective data (in physical) |
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What is the purpose of assessment?
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make a judgement or diagnoses
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What is diagnostic reasoning?
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process of analyzing health data and drawing conclusions to identify diagnoses
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What are the six phases of the nursing process?
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1. assessment
2. diagnsis 3. outcome identification 4. planning 5. implementation 6. evaluation |
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What are the six parts of a health assessment?
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-review of the clinical record
-health history -physical examination -functional assessment -risk assessment -review of the literature |
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What is a nursing diagnosis?
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a clinical judgement about a persons response to an actual or potential health state
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What are the three types of nursing diagnoses?
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1. actual diagnoses
2. risk diagnoses 3. wellness diagnoses |
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What is a medical diagnosis?
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diagnosis that evaluates the cause or etiology of the disease
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What are the four different types of databases?
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-complete
-focused or problem centered -follow-up -emergency |
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What is a complete database?
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complete health history and full physical exam
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What is a focused or problem centered database?
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for a limited or a short term problem
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What is a follow up database?
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when the status of identified problems are evaluated at regulaar and appropriate intervals
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What is an emergency database?
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a rapid collection of data, diagnosis must be swift and sure
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