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Evidence Based Practice - Health Assessment from Missy
Terms in this set (30)
What is assessment?
Collection of subjective and objective data about a patient's health.
What is subjective data?
Information provided by the patient.
What is objective data?
Information obtained by the health care provider through physical assessment, patient's record, and lab studies.
What is the purpose of assessment?
Make a judgement or diagnosis
What is the database?
-Totality of information available about the patient.
-Used to make a judgment or diagnosis.
What is Diagnostic Reasoning?
Process of analyzing health data and drawing conclusions to identify a diagnosis.
Diagnostic reasoning is also knows as what?
What is critical thinking
Multidimensional thinking process needed for sound diagnostic reasoning & clinical judgement.
What are the 4 major components of diagnostic reasoning?
-Attending to initially available cues
-Formulating diagnostic hypothesis
-Gathering data relative to tentative hypotheses
-Evaluating each hypothesis with the newly collected data --> arriving at final diagnosis
What is a cue?
Piece of information (sign, symptom, or lab data)
What is a hypothesis?
Tentative explanation for a cue or set of cues that can be used as a basis for further investigation.
What is the Nursing Process
-A dynamic, interactive process in which practitioners move back and forth within the steps.
-Problem solving approach
What are the 6 phases (steps) of the "Nursing Process"
-Use evidence-based assessment techniques
-Document relevant data
-Compare clinical findings with normal and abnormal variation and developmental events
-Identify expected outcomes
-Individualize to the person
-Realistic and measurable
-Include a timeline
-Set timelines for outcomes
-Integrate evidence-based trends and research
-Document POC (plan of care)
-Implement in a safe and timely manner
-Use evidence-based interventions
-Collaborate with colleagues
-Use community resources
-Coordinate care delivery
-Provide health teaching and health promotion
-Document implementation and any modification
-Progress toward outcomes
-Conduct systematic, ongoing, criterion-based evaluation
-Include patient and significant others
-Use ongoing assessment to revise diagnoses, outcomes, plan
-Disseminate results to patient and family
-Has no experience with a specified patient population
-Uses rules to guide performance
-Understands a patients situation as a whole rather than as a list of tasks
-Arrives at a clinical judgment in one leap
-Has intuitive grasp of a clinical situation and zeros in on the accurate solution
First-level priority problems
-High priority (immediate)
-ABCs + V
Second-level priority problems
-Require prompt intervention but not life threatening
-Mental status changes
-Untreated medical problems
-Acute urinary elimination problems
-Abnormal lab values
-Risk for infection, safety, or security
Third-level priority problems
-Health problems that are important to patients health but can be addressed after more urgent health problems are addressed.
-Health problems that do not fit into first or second priority problems (lack of knowledge, activity, rest, family coping)
What is evidence-based practice
Systematic approach to practice that uses the best evidence, clinician's experience, and patients preferences & values to make decisions about care and treatment
What 4 factors does clinical decision making depend on?
-Best evidence from a critical review of research literature
-Patient's own preferences
-Clinician's own experiences
What is the "Holistic Health Model"?
-Assesses the "whole person" because it views mind, body, and spirit as interdependent and functioning as a whole withing the environment.
A medical diagnosis is used to evaluate:
A person's state of health
A nursing diagnosis is best described as:
A clinical judgments about a person's response to actual or potential health state.
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