Evidence-based assessment discusses the characteristics of:
1. evidence-based practice
2. diagnosis reasoning
3. the nursing process and
4. critical
... [Show More] thinking
Assessment
The collection of data about an individual's health state.
Biomedical model
the Western European/North American tradition that views health as the absence of disease.
Complete database
a complete health history and full physical examination
Critical thinking
simultaneously problem solving while self-improving one's own thinking ability
Diagnostic reasoning
a method of collecting and analyzing info with the following components:
1. attending to initially available cues
2. formulating diagnostic hypotheses
3. gathering data relative to the tentative hypotheses
4. evaluating each hypotheses with the new data collected
in order to arrive at a final diagnosis
Emergency database
rapid collection of the database, often compiled concurrently with lifesaving measures
Environment
the total of all the conditions and elements that make up the surroundings and influence the development of a person
Evidence-based practice
a systematic approach emphasizing the best research evidence, the clinician's experience, patient preferences and values, physical examination, and assessment
Focused database
used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system
Follow-up database
used in all settings to monitor progress of 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
Nursing Process
a method of collecting and analyzing clinical information with the following components:
(1) assessment
(2) diagnosis
(3) outcome identification
(4) planning
(5) implementation and
(6) evaluation
Objective data
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
Prevention
any action directed toward promoting health and preventing the occurrence of disease
Subjective data
what the person says bout himself or herself during history taking
Wellness
a dynamic process and view of health; a move toward optimal functioning
Amount of data gathered during assessment varies with:
1. person's age
2. developmental state
3. physical condition
4. risk factors and
5. culture
Name and define Step 1 of Nursing Process
ASSESSMENT
The collection of data about the individual's health state
Information collected allows the nurse to make a clinical judgment or diagnosis
Name and define Step 2 of Nursing Process
DIAGNOSIS
Compare clinical findings
Interpret data
- identify clusters/cues
- make/test hypotheses
- derive diagnosis
Validate diagnosis
Document diagnosis
Name and define Step 3 of Nursing Process
OUTCOME IDENTIFICATION
Identify expected/culturally appropriate outcomes
- Individualize outcomes to the person
- Outcomes must be realistic and measurable
- Develop a timeline [Show Less]