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RNSG 1215 Exam 1 Key Terms. Updated 2024.
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RNSG 1215 Exam 1 Key Terms. Updated 2024.Objective data
What you as the health professional observe by inspecting, percussing, palpating and auscultating during
the physical exam
Database
Subjective data, objective data, the patient's record and laboratory studies form this
From the database you:
Make a clinical judgment or diagnosis about the individual's health state, response to actual or potential
health problems, and life processes
Diagnostic reasoning
The process of analyzing health data and drawing conclusions to identify diagnoses
Hypothetico-deductive process
Hypothesis forming and deductive reasoning
-Has 4 major components:
1) Attending to initially available cues
2) Formulating diagnostic hypotheses
3) Gathering data relative to the tentative hypotheses
4) Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis
Cue
Piece of information, sign or symptom or a piece of lab data
Hypothesis
Tentative explanation for a cue or a set of cues that can be used as a basis for further investigation
Nursing Process
1) Assessment
2) Diagnosis
3) Outcome identification
4) Planning
5) Implementation
6) Evaluation
Novice
No experience with a specific patient population and uses rules to guide performance
Competent
,Takes 2-3 years in similar clinical situations to achieve this
-You see actions in the context of arching goals or daily plans for patients
Proficient
Understands a patient situations as a whole rather than as a list of tasks
-You can see long-term goals for the patient
Expert
Vault over the steps and arrive at a clinical judgment in one quick leap
-Intuitive grasp of a clinical situation and zeroes in on the accurate solution
-Has a storehouse of experience concerning which interventions have worked in the past
Assessment
-Collect data (review the clinical record, health history, physical exam, functional assessment, risk
assessment, review of the literature)
-Use EBA techniques
-Document relevant data
Diagnosis
-Compare clinical findings with normal and abnormal variation and developmental events
-Interpret data (identify clusters of cues, make hypotheses, test hypotheses, derive diagnoses)
-Validate diagnoses
-Document diagnoses
Outcome identification
-Identify expected outcomes
-Individualize to the person
-Culturally appropriate
-Realistic and measurable
-Include a timeline
Planning
-Establish priorities
-Develop outcomes
-Set timelines for outcomes
-Identify interventions
-Integrate evidence-based trends and research
-Document plan of care
Implementation
-Implement in a safe and timely manner
-Use evidence-based interventions
-Collaborate with colleagues
-Use community resources
,-Coordinate care delivery
-Provide health teaching and health promotion
-Document implementation and any modifications
Evaluation
-Progress toward outcomes
-Conduct systematic, ongoing, criterion-based evaluation
-Include patient and significant others
-Use ongoing assessment to revise diagnoses, outcomes, plan
-Disseminate results to patient and family
Critical thinking
Goes beyond knowing the pathophysiology of a disease process and requires you to put important
assessment cues together to determine the most likely cause of a clinical problem and develop a
solution
Rates of incorrect diagnoses:
As high as 10-15%
-Primary causes is the clinician's bias
First-level priority problems
Emergent, life threatening and immediate
-Establishing an airway or supporting breathing
Second-level priority problems
Second in urgency
-Requiring your prompt intervention to forestall further deterioration
-EX: mental status change, acute pain, acute urinary elimination problems, untreated medical problems,
abnormal lab values, risks of infection, risk to safety or security
Third-level priority problems
Important to the patient's health but can be addressed after more urgent health problems are addressed
-Interventions are more long-term and the response to treatment is expected to take more time
Collaborative problems
Approach to treatment involves multiple disciplines
Evidence-based practice
The idea that all patients deserve to be treated with the most current and best-practice techniques
-This works in combination with the clinician's experience and the patient's preferences and values to
make decisions about care and treatment
Clinical decision making depends on:
, 1) The best evidence from a critical review of research literature
2) The patient's own preferences
3) The clinician's own experience and expertise
4) Physical exam and assessment
How long it takes for research findings to be implemented into practice:
Up to 17 years
Four Types of Databases
1) Complete (Total health)
2) Focused/Problem-centered
3) Follow-up
4) Emergency
Complete (Total Health) Database
Includes a complete health history and a full physical exam
-It describes the current and past health state and forms a baseline for all future changes to be
measured
-Yields the first diagnoses
-Often collected in a primary care setting or acute hospital care
-Must screen for pathology
Focused/Problem-Centered Database
-For a limited or short-term problem
-Smaller in scope and more targeted than the complete database
-Concerns mainly one problem, one cue complex or one body system
-Used in all settings
Follow-up Database
-The status of any identified problems should be evaluated at regular and appropriate intervals
-Used in all settings for short-term and chronic problems
Emergency Database
-Urgent, rapid collection of crucial info and often is compiled concurrently with lifesaving measures
_____________ and ____________ form the core of nursing practice.
Health promotion, disease prevention
Prevention can be achieved through:
Counseling from primary care providers designed to change people's unhealthy behaviors related to
smoking, alcohol and other drug use, lack of exercise, poor nutrition, injuries and STIs
Health promotion is:
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