Health Assessment Exam 1 Chapter 1
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Created by:
bsheehy014 on February 5, 2012
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Description:
Chapter 1 Evidence-Based Assessment
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26 terms
Terms | Definitions |
|---|---|
 Subjective Data | any info that the patient gives you |
| Objective Data | info that we as practitioners find through tests, etc. |
| What are the 6 Phases of the Nursing Process? | 1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation |
| Complete (Total Health) Data Base | A complete health history and physical examination; describes the past and present health status, perception of health, strengths, coping patterns, support systems, development tasks, or risk factors. |
| Episodic/Focused/Problem-Centered Data Base | Concerns one problem or one body system. For example, 2 days after surgery a patient develops a cough so our assessment would primarily focus upon the respiratory system |
| Follow-Up Data Base | used in all settings to monitor progress on short-term or chronic health problems; a follow up to anything such as an ankle sprain |
| Emergency Data Base | rapid collection of the database, often compiled concurrently with lifesaving measures |
| Bradychardia | BPM of 60 or below |
| Tachychardia | BPM of 100 or above |
| Regular Temperature | 95-99.9 *F |
| Oral Temp | most popular form of taking temperature; has to be taken for 3-5 minutes; |
| Rectal Temp | least popular form of taking temperature but most accurate; must be done for 2-3 minutes; Never done during rectal bleeding; Best used when oral seal not possible or in peds un 3-4 years |
| Axillary Temp | least accurate way to take temperature; used infrequently; must be taken for 10 minutes; |
| TMT | ear temp; automated, research suggests it is not as accurate as other methods; |
| What are the vital signs? | Temperature, Pulse, Blood Pressure, Respiratory Rate, Pain |
| Pulse | Measures rate, rhythm of beating heart, also indicates force of blood (weak, thready, bounding, or simply put, strong) |
| Apical Pulse | Heart pulse in all age groups, used for different conditions |
| Respirations | Relaxed, regular, automatic, and silent chest movement, typically between 12 and lower 20s. Fluctuates due to many conditions; In babies or little kids, observe the abdomen |
| Blood Pressure | Average BP 120/70; Influenced by race, sex, weight, exercise, emotions, stress, and cuff size; Factors controlling BP include cardiac output; peripheral vascular resistance, blood volume, viscosity, and elasticity; |
| Biomedical Model | the Western European/North American tradition that views health as the absence of disease; |
| Assessment | the collection of data about an individual's health state |
| Critical Thinking | simultaneously problem-solving while self-improing one's own thinking ability |
| Diagnostic Reasoning | a method of collecting and analyzing clinical info with the following components: (1) attending to initially available cues (2) formulating diagnostic hypotheses (3) gathering data relative to the tentative hypotheses (4) evaluating each hypothesis with the new data collected, and (5) arriving at a final diagnosis |
| Environment | The Total of all the conditions and elements that make up the surroundings and influence the development of a person |
| Evidence-Based Practice | a systematic approach emphasizing the best research evidence, the clinician's experience, patient preferences, and values, physical examination, and assessment |
| Nursing Diagnosis | used to evaluate the response of the whole person to actual or potential health problems |
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