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