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31 Cards in this Set
- Front
- Back
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Subjective Data
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What the person says about themselves
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Objective data
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What you observe about a patient
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Database
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subjective, objective data, patient's record, and laboratory tests
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diagnostic reasoning
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process of analyzing health data and drawing conclusions to identify diagnoses.
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Nursing process
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dynamic, interactive process
assessment, diagnosis, outcome identification, planning, implementation, and evaluation |
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identify assumptions
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recognize that you could take information for granted or see it as fact when actually there is no evidence for it.
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identifying an organized and comprehensive approach
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you may use any organized format for assessment that is feasible for you.
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validation
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checking the accuracy and reliability of data
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normal vs abnormal
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spotting abnormal signs and symptoms leads to problem identification.
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making inferences
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involves interpreting the data and deriving a correct conclusion about the health status.
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clustering related cues
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helps to see a pattern among data
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relevant vs irrelevant
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considering which data are important for a health problems or health promotion needs,
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recognizing inconsistencies
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recognizing conflicting information and clarifying the situation
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Identifying missing information
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gaps in data or a need for more data to make a diagnosis.
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promoting health
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identifying risk factors and offering consouling to promote health
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Nursing diagnosis
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clinical judgments aobut a person's response to an actual or potential health state.
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actual diagnoses
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existing problems that are amenable to independent nursing interventions.
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Risk diagnoses
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potential problems that an individual does not currently have but is particularly vulnerable to developing.
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Wellness diagnoses
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focus on strengths and reflect an individual's transition to a higher level of wellness.
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First level priority problems
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emergent, life-threatening, and immediate problems i.e ABC
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Second Level priority problems
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those requiring your prompt intervention to forestall further deterioration. i.e mental status change, acute pain, urinary problems, risk for infection, abnormal labs, etc
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third level priority problems
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those that are important to the patient's health but can be addressed after more urgent health problems are addressed
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collaborative problems
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those which the approach to reatment involves multiple disciplines
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patient centered outcomes
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specific, measurable results you expect will show an improvement in the person's problem after treatment.
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specific intervention
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aim to prevent, manage or resolve health problems; the health care plan.
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Evidence based practice
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systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience as well as the patient preferences and values to make decisions about care and treatment.
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Complete database
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complete health history and a full physical exam. includes current, past health state and forms a baseline.
forms first diagnose |
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focused or problem centered database
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for an acute problem.
mini database, smaller in scope and more targeted focused on one problem, cue, or body system. used in all settings. |
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follow up database
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the status of any identified problems are evaluated a t regular and appropriate intervals.
used to follow up short term and chronic problems |
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Emergency database
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this is used for rapid collection of data, often compiled concurrently with lifesaving measures.
diagnosis is made swiftly and surely |
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holistic health
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consideration of the whole person.
views the mind, body, and spirit as interdependent and functions as a whole within the environment health depends on all theses factors working together |
