Term
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Definition
| validates the importance of using assessment. purpose of assessment is to made a judgement or diagnosis. |
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Term
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Definition
| subjective data- what the person says about themselves during history taking |
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Term
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Definition
| objective data- what you as the heath professional observe by inspecting, percussing, palpating, and auscultating during physical examination. |
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Term
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Definition
database- patient's records, laboratory studies, subjective and objective data.
from the database you make a clinical judgement or diagnosis about the individuals health state or response to actual or risk health problems and life processes, as well as diagnoses about higher levels of wellness. |
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Term
Diagnostic reasoning
cue vs hypothesis |
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Definition
diagnostic reasoning is the process of analyzing health data and drawing conclusions to indentify diagnoses.
use the hypothetic-deductive process:
1. attend to initially available cues
2. formulating diagnostic hypothesis
3. gathering data relevant to the tentative hypotheses
4. evaluating each hypothesis witht he need data collected, thus arriving at a final diagnosis.
cue- a piece of information, a sign or symptom, or a piece of laboratory data.
hypothesis- a tentative explanation for a cue or a set of cues that can be used as a basis for further investigation. |
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Term
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Definition
The nursing process is the standards of practice in nursing. it is a problem solving approach including six phases:
1. assessment
2. diagnosis
3. outcome identification
4. planning
5. implementation
6. evaluation |
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Term
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Definition
Assessment:
-Collect data: review clinical record, health history, physical exam, functional assessment, risk assessment, review of the literature
- Use evidence-based techniques
- Document relevant data |
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Definition
Diagnosis:
-Compare clinical finding with normal and abnormal variation and developmental events
-Interpret data: identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses
-Validate diagnoses
-Document diagnoses |
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Term
| Outcome identification phase |
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Definition
Outcome Identification:
- Identify expected outcomes
- Individualize to the person
- Culturally appropriate
- Realistic and measurable
- Include a timeline |
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Term
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Definition
Planning:
- Establish priorities
- Develop outcomes
- Set timelines for outcomes
- Identify interventions
- Integrate evidence based trends and research
- document plan of care |
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Term
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Definition
Implementation:
- Implement in a safe and timely manner
- Use evidence based interventions
- Collaborate with colleagues
- Use community resources
- Coordinate care delivery
- Promote heath teaching and health promotion
- Document implementation and any modification |
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Term
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Definition
Evaluation:
- Progress tower outcomes
- Conduct systematic, ongoing, criterion based evaluation
- Include patient and significant others
- Use ongoing assessment to revise diagnosis, outcomes, plan
- Disseminate results to patient and family |
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Term
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Definition
| validation- checking the accuracy and reliability of data |
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Term
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Definition
| clustered cues- help see a relationship among data |
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Term
| making inferences (or hypotheses) |
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Definition
| Making and inference or hypotheses- involves interpreting data and deriving a correct conclusion about the health status |
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Term
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Definition
Nursing diagnoses- are clinical judgements about a persons response to an actual or potential health state.
1. actual diagnoses- existing problems that are amenable to independent nursing interventions
2. risk diagnoses- potential pronlems that an individual does not currently have but is particularly vulnerable to developing
3. wellness diagnoses- which focus on strengths and reflect an individual's transition to a higher level of wellness |
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Term
| First-level priority problem |
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Definition
| First-level priority problems- are those that are emergent, life threatening, and immediate |
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Term
| Second-level priority problems |
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Definition
| Second-levle priority problems- are htose thtat are net in urgency–those requiring your prompt intervention to forestall further deterioration |
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Term
| Third-level prority problems |
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Definition
| Third-level priority problems- are those that are important to the patients health but cane be addressed after more urgent health problems are addressed |
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Term
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Definition
| Collaborative problems- are htose in which the approach to treatment involves multiple disciplines. collaborative problems are certain physiological complication in which nurses have the primary responsibility to diagnose the onset and monitor the changes ins tat us. |
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Term
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Definition
| Nursing Interventions- will achieve your outcomes. these interventions aim to prevent, manage or resolve health problems. this is the health care plan. for specific interventions, state who should perform the interventions, when and how often, and the method use |
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Term
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Definition
| EBP- is a systematic approach to practice that emphasized the use of best evidence in combination with the clinicians experience as well as the patients preferences and values, to make decisions about are and treatment. |
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Term
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Definition
| Holistic health- consideration of the whole person. view the mind, body, and spirit as interdependent and functioning as a whole within the environment. health depends on all these factors working together. in holistic model, assessment factors are expanded to include such things as culture and values, family and social roles, self-care behaviors, job-related stress,developmental tasks and failures and frustrations in life. all are significant to health. |
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