Shared Flashcard Set

Details

Ha
exam 1
8
Nursing
Undergraduate 1
02/10/2012

Additional Nursing Flashcards

 


 

Cards

Term

Assessment - Point of Entry in an Ongoing Process

Definition

Assessment is the collection of data about the individual's health state

 

"subjective data" is what the person says about himself or herself during history taking

 

"Objective data" is what you is the health professional observed by inspecting, per cussing, palpitating, and auscultating during the physical examination

 

together with the patient's record and lab studies these elements form the "database"

 

from the database you make a clinical judgment or "diagnosis"

 

the purpose of assessment is to make a judgment or diagnosis

 

all healthcare treatment and decisions are made based on the data you gather - it must be complete and correct

Term

Diagnostic Reasoning in Clinical Judgment

Definition

"diagnostic reasoning" is the process of analyzing health data and drawing conclusions to identify diagnoses

 

it has four major components:

1. Attending to initially available cues

2. Formulating diagnostic hypotheses

3. Gathering data relative to the tentative hypothesis

4. Evaluating each hypothesis with the new data collected 

Term

1. Assessment

Definition

COLLECT DATA

Review of the clinical record

interview

health history

physical examination

functional assessment

consultation

review of the literature

Term

2. Diagnosis

Definition

INTERPRET DATA

identify clusters of cues

make inferences

 

Validate inferences

 

Compare clusters of cues with definition and defining characteristics

 

Identify related factors

 

Document the diagnosis

Term

3. Outcome Identification

Definition

Identify expected outcomes

 

individualize to the person

 

realistic and measurable

 

include a timeframe

Term

4. Planning

Definition

Establish priorities

 

develop outcomes

 

set time frames for outcomes

 

identify interventions

 

document plan of care

Term

5. Implementation

Definition

Review the planned interventions

 

Schedule and coordinate the person's total health care

 

collaborate with other team members

 

supervise implementation of the care plan by delegating appropriate responsibilities

 

counsel the person and significant others

 

involve the person in the healthcare

 

refer individuals who require continuing care

 

document the care provided

Term

6. Evaluation

Definition

Refer to establish outcomes

 

and evaluate the individual's condition and compare actual outcomes with expected outcomes

 

summarize the results of the evaluation

 

identify reasons for the person's failure, if indicated, to achieve expected outcomes stated in the plan of care

 

take corrective action to modify the plan of care as necessary

 

document the evaluation of the persons achievement of outcomes in the modifications, if any, in the plan of care

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