Nursing Study Guide
Chapter 1-Evidence Based Assessment
Assessment: the collection of data about an individuals health state
Subjective Data: what the person says about themselves during history taking
Evidence: collected body of data from lab tests and medical history
Objective Data: what a health professional observes by inspecting, percussing, palpating, and auscultating during a physical exam
Diagnostic Reasoning: a method of collecting and analyzing clinical information with the following components
Attending to initially available cues
Cue: a piece of information (sign or symptom) or a piece of laboratory information
Formulating diagnostic hypothesis
Hypothesis: a tentative explanation for a cue or a set of cues that can be ued for a basis for further investigation
Gathering data relative to the tentative hypothesis
Evaluating each hypothesis with the new data collected
Arriving at the final diagnosis
Nursing Process: a method of collecting and analyzing clinical information with the six main components
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Nursing Diagnosis: clinical judgments used to evaluate the response of the whole person to actual or potential health problems
First Level Priority Problems: emergent, life threatening problems prioritized by A, B, C, V
A: airway problems
B: breathing problems
C: Cardiac/circulation problems
V: vital sign concerns
Second Level Priority: problems that run next in urgency that require your prompt intervention to forestall further deterioration
Ex: mental status change, untreated medical problem, acute pain, acute urinary elimination problems, abnormal lab values, or risk of infection
Third Level Priority: health problems that don’t fit into severe categories
Ex: lack of activity, rest or family coping
Collaborative Problems: problems in which the approach to treatment involves multiple disciplines
Steps in Collecting Four Types of Data:
1. The
Assessment: the collection of data about an individuals health state
Subjective Data: what the person says about themselves during history taking
Evidence: collected body of data from lab tests and medical history
Objective Data: what a health professional observes by inspecting, percussing, palpating, and auscultating during a physical exam
Diagnostic Reasoning: a method of collecting and analyzing clinical information with the following components
Attending to initially available cues
Cue: a piece of information (sign or symptom) or a piece of laboratory information
Formulating diagnostic hypothesis
Hypothesis: a tentative explanation for a cue or a set of cues that can be ued for a basis for further investigation
Gathering data relative to the tentative hypothesis
Evaluating each hypothesis with the new data collected
Arriving at the final diagnosis
Nursing Process: a method of collecting and analyzing clinical information with the six main components
1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
Nursing Diagnosis: clinical judgments used to evaluate the response of the whole person to actual or potential health problems
First Level Priority Problems: emergent, life threatening problems prioritized by A, B, C, V
A: airway problems
B: breathing problems
C: Cardiac/circulation problems
V: vital sign concerns
Second Level Priority: problems that run next in urgency that require your prompt intervention to forestall further deterioration
Ex: mental status change, untreated medical problem, acute pain, acute urinary elimination problems, abnormal lab values, or risk of infection
Third Level Priority: health problems that don’t fit into severe categories
Ex: lack of activity, rest or family coping
Collaborative Problems: problems in which the approach to treatment involves multiple disciplines
Steps in Collecting Four Types of Data:
1. The