Critical Thinking In Health Assessment

Front 1

Subjective Data

Back 1

What the patient says about himself during history taking.

Front 2

Objective Data

Back 2

What the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination.

Front 3

Diagnostic Reasoning

Back 3

Process of analyzing health data and drawing conclusions to identify diagnoses, based on scientific method.

Front 4

Diagnostic Reasoning 4 Elements

Back 4

1. attending to clues
2. formulating hypotheses
3. gathering data relative to hypotheses
4. Evaluating each hypotheses with new data to arrive at a diagnosis

Front 5

Nursing Process

Back 5

a problem solving approach to clinical judgments based on scientific method

Front 6

Nursing Process
6 Steps

Back 6

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

Front 7

Critical Thinking

Back 7

1. Identifying Assumptions
2. Organized and Comprehensive Approach
3. Validation
4. Normal from Abnormal
5. Making Inferences
6. Clustering related cues
7. Relevant from irrelevant
8. Recognize inconsistencies
9. Identifying patterns
10. Missing information
11. Promoting health
12. Actual and potential risks
13. Setting priorities
14. Patient-centered expected outcomes
15. Specific Interventions
16. Evaluating and correcting thinking
17 Comprehensive plan

Front 8

Setting Priorities
First Level

Back 8

ABCs
Airway problems
Breathing problems
Cardiac/Circulation problems
Signs (vital sign concerns)

Front 9

Setting Priorities
Second-level

Back 9

MAA-U-AR
Mental status changes
Acute Pain
Acute urinary elimination problems
Untreated medical problems requiring immediate attention
Abnormal Lab values
Risks of infection, safety, security

Front 10

Setting Priorities
Third-level

Back 10

Health problems that do not fit into the above categories
Eg. problems with lack of knowledge, activity, rest, family, coping

Front 11

Nursing Diagnoses

Back 11

Clinical judgments about a person's response to an actual or potential health state.
1. Actual diagnoses
2. Risk Diagnoses
3. Wellness diagnoses

Front 12

Potential problems that an individual does not currently have but is particularly vulnerable to developing

Back 12

Risk Diagnoses

Front 13

Existing Problems that are amenable to independent nursing interventions

Back 13

Actual Diagnoses

Front 14

Focus on strengths and reflect an individual's transition to a higher level of wellness.

Back 14

Wellness Diagnoses

Front 15

Western tradition which views health as the absence of disease

Back 15

Biomedical model

Front 16

A dynamic process, a move toward optimal functioning

Back 16

Wellness

Front 17

Views the mind, body and spirit, as interdependent and functioning as a whole within the environment.

Back 17

Holistic Health

Front 18

A database that includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured.

Back 18

Complete Database

Front 19

A database for limited, short-term problems. It is used in all settings and focuses on one problem, concern, cue, or body system.

Back 19

Episodic or Problem-centered Database

Front 20

A database that focuses on the status of any identified problems that should be evaluated at regular intervals.

Back 20

Follow-up Database

Front 21

A database that calls for a rapid collection of the data, often compiled concurrently with lifesaving measures.

Back 21

Emergency Database