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21 Cards in this Set
- Front
- Back
Subjective Data
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What the patient says about himself during history taking.
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Objective Data
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What the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination.
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Diagnostic Reasoning
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Process of analyzing health data and drawing conclusions to identify diagnoses, based on scientific method.
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Diagnostic Reasoning 4 Elements
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1. attending to clues
2. formulating hypotheses 3. gathering data relative to hypotheses 4. Evaluating each hypotheses with new data to arrive at a diagnosis |
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Nursing Process
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a problem solving approach to clinical judgments based on scientific method
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Nursing Process
6 Steps |
1. Assessment
2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation |
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Critical Thinking
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1. Identifying Assumptions
2. Organized and Comprehensive Approach 3. Validation 4. Normal from Abnormal 5. Making Inferences 6. Clustering related cues 7. Relevant from irrelevant 8. Recognize inconsistencies 9. Identifying patterns 10. Missing information 11. Promoting health 12. Actual and potential risks 13. Setting priorities 14. Patient-centered expected outcomes 15. Specific Interventions 16. Evaluating and correcting thinking 17 Comprehensive plan |
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Setting Priorities
First Level |
ABCs
Airway problems Breathing problems Cardiac/Circulation problems Signs (vital sign concerns) |
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Setting Priorities
Second-level |
MAA-U-AR
Mental status changes Acute Pain Acute urinary elimination problems Untreated medical problems requiring immediate attention Abnormal Lab values Risks of infection, safety, security |
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Setting Priorities
Third-level |
Health problems that do not fit into the above categories
Eg. problems with lack of knowledge, activity, rest, family, coping |
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Nursing Diagnoses
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Clinical judgments about a person's response to an actual or potential health state.
1. Actual diagnoses 2. Risk Diagnoses 3. Wellness diagnoses |
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Potential problems that an individual does not currently have but is particularly vulnerable to developing
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Risk Diagnoses
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Existing Problems that are amenable to independent nursing interventions
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Actual Diagnoses
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Focus on strengths and reflect an individual's transition to a higher level of wellness.
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Wellness Diagnoses
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Western tradition which views health as the absence of disease
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Biomedical model
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A dynamic process, a move toward optimal functioning
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Wellness
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Views the mind, body and spirit, as interdependent and functioning as a whole within the environment.
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Holistic Health
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A database that includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured.
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Complete Database
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A database for limited, short-term problems. It is used in all settings and focuses on one problem, concern, cue, or body system.
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Episodic or Problem-centered Database
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A database that focuses on the status of any identified problems that should be evaluated at regular intervals.
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Follow-up Database
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A database that calls for a rapid collection of the data, often compiled concurrently with lifesaving measures.
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Emergency Database
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