Jarvis health assessment ch1
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25 terms
Terms | Definitions |
|---|---|
 Subjective data | What the person says about himself/herself during health history taking |
| Objective data | What you observe by inspecting, percussing, palpating, and auscultating during physical examination |
| Diagnostic reasoning | Process of analyzing health data and drawing conclusions to identify diagnosis |
| Nursing process | 6 phases- assessment, diagnosis, outcome identification, planning, implementation, evaluation, assessment |
| Assessment | Collect data about an individual's health state. i.e. Health history, physical examination, risk assessment, review of clinical record, use evidence based techniques |
| Diagnosis | Compare clinical findings with normal and abnormal variation and developmental events, interpret data, document diagnosis |
| Outcome identification | Identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include a timeline |
| Planning | Establish priorities, develop outcomes, set timelines, identify interventions, document plan of care |
| Implementation | Implement in a safe and timely manner, use evidence based interventions, provide health teaching, document implementation and any modification |
| Evaluation | Progress towards outcomes, conduct systematic ongoing criterion based evaluation, include patient and significant others |
| Nursing diagnosis | This is a clinical judgment about individual, family, or community responses to actual or potential health problem/life processes. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. |
| First level priority problems | those that are emergent, life threatening, and immediate(establishing and airway, breathing) |
| Second level priority problems | those that are next in urgency requiring your prompt intervention to forestall further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results |
| Third level priority problems | those that are important to the patient's health but can be addressed after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low self esteem) |
| Collaborative problems | REQUIRES INTERVENTION FROM MORE THAN THE ONE DISCIPLINE OF THE HEALTHCARE PROCESS. (rehab, pharmacy, discharge planning, cardiopulmonary) Most problems are collaborative |
| 4 types of data based on clinical situation | Complete total health database, focused or problem centered database, follow up database, emergency database |
| Holistic health | the view that the mind, body, and spirit are interdependent and function as a whole within the environment |
| Database | Patients record, laboratory studies, subjective and objective data all together |
| Hypothetico-deductive process | Attending to initially available cues, formulating diagnostic hypotheses, gathering data relative to the tentative hypotheses, evaluating each hypothesis with the new data collected |
| Hypothesis | Tentative explanation for a cue or a set of clues that can be used as a basis for further investigation |
| Evidence based practice (EBP) | clinical decision-making that integrates the best available research with clinical expertise and patient characteristics and preferences |
| Complete total health database | Complete health history and physical examination. It describes current and past health state and forms a baseline against which all future changes can be measured. Yields first diagnoses |
| Focused or problem centered database | For limited or short term problem. Collect "mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one body system |
| Follow up database | used in all settings to monitor progress on short-term or chronic health problems |
| Emergency database | rapid collection of the database, usually compiled concurrently with life-saving measures |
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