Evidence based practice
a systematic approach emphasizing the best research evidence, the clinicians experience, patient preferences and values, physical
... [Show More] examination, and assessment.
Subjective Data
SYMPTOMS: What the person says about him or herself during history taking.
Objective Data
SIGNS: What the health professional observes by inspecting, palpating, percussing and osculating during the physical examination.
Diagnostic Reasoning
the process of taking the information provided and drawing conclusions to identify diagnoses. (deductive reasoning and formation of hypothesis)
Sources of Data
Client
Family
Healthcare Providers
Chart/Medical Records
Hypothesis
A tentative explanation for a cue or a set of cues that can be a basis for further investigation.
Critical Thinking
simultaneously problem-solving while self improving one's own thinking ability
Nursing Diagnosis
used to evaluate the response of the whole person to actual or potential health problems
Medical Diagnosis
used to evaluate the cause and ethnology of disease; focus is on the function or malfunction of a specific organ system
Assessment
the collection of data about an individual's health state
Complete Database
a complete health history and full physical examination
Focused Database
one used for a limited or short term problem; what brought the patient there
Emergency Database
rapid collection of crucial information; medications and allergies
Ongoing/Follow-up Database
used in all settings to monitor progress on short term or chronic health problems
Holistic Health
the view that the mind, body and spirit are interdependent and function as a whole within the environment.
Prevention
any action directed toward promoting health and preventing the occurrence of disease
Primary Prevention
immunizations, use of seat belts
Secondary Prevention
early identification: mammograms, colonoscopy, screenings
Tertiary Prevention
treatment, medications, follow-up studies
Social Determinants of Health
Environment, healthy childhood development, socioeconomic status, social support networks
Non-Verbal Communication
communication using body movements, gestures, and facial expressions rather than speech
Cultural Competence
Application of knowledge, skills, attitudes or personal attributes required by nurses to maximize respectful relationships with diverse populations
Cultural Safety
Promote greater equity, looking at power imbalances by focusing on root cause.
The Interview Goal
To record a complete health history
Tasks in an interview
Gather complete & Accurate data, establish rapport, trust, respect and teach the patient
Closed or direct question
Yes or no
Open-ended question
asks for narrative information
False Assurance
Now don't worry, I'm sure you will be fine.
Symptom
Subjective sensation the patient feels from the disorder
Sign
Objective abnormality detected on physical examination
Biographical Data
Name, Address, phone number, DOB
P
Provocative, palliative [Show Less]