Nur 230 exam 1
Follow up data base - ✔️✔️Short term/ chronic problems, problems should be
evaluated at regular and appropriate intervals
What has changed, worse/better, coping strategies used
Evidenced based practice - ✔️✔️Patients deserve to be treated with most current and
best practice techniques
Systematic approach to practice that emphasizes the use of best evidence in
combination with clinicians experience as wel as the patients preferences and values
Diagnosis - ✔️✔️Compare findings that are normal and abnormal, and developmental
events, interpret data, identify cluster of clues, make hypotheses and test it, derive
diagnosis, validate and document diagnosis
Assessment - ✔️✔️Collect data subjective and objective, it is an ongoing processes
not a one time thing
Review of the clinical record, health history, physical examination, functional
assessment, risk assessment, review of the literature , use evidence-based assessment
techniques, document relevant data
Subjective data - ✔️✔️What the patients says about their self during history taking, or
what a close family member or friend say, cultural/spiritual , mental status ,
Objective data - ✔️✔️Observations made during physical examination, general survey,
vital signs, head-to-toe assessment
Comprehensive "admission assessment" - ✔️✔️Health history and physical exam,
enables complete picture of patients health status
Episodic/focused "shift assessment" - ✔️✔️A comprehensive asses that focuses more
on a specific things
Emergency assessment - ✔️✔️Not going to take the time to do comprehensive
Follow-up assessment - ✔️✔️What changed, better/worse, what coping strategies
used
physical examination - ✔️✔️Inspection, palpitation, percussion, auscultation
Nursing process - ✔️✔️Assessment, diagnosis, planning, implementation, evaluation
(ADPIE)
, Outcome identification - ✔️✔️Identify expected outcomes, individualize for patient,
culturally appropriate, realistic and measurable and have a time frame
Planning - ✔️✔️Establish priorities, develop outcomes, set timelines for outcomes,
identify interventions, integrate evidence based trends/research, document plan of care,
development outcomes, identity interventions, document plan of care
First level priority problem - ✔️✔️Are emergent, life-threatening, or immediate (ABCV)
airway, breathing cardiac/cardiovascular probs, vital sign concerns
Second level priority problem - ✔️✔️Next in urgency, prompting you to forestall further
deterioration (mental changes, acute pain, urinary elimination, abnormal lab value, risk
of infection
Third level problems - ✔️✔️Important to patients health, but can be addressed later or
after more urgent steps taken care of, more long term, response to treatment expected
to take more time
Collaborative problems - ✔️✔️Approach to treatment involves multiple disciplines
nurse's diagnosis the onset and monitor the changes in status
Implementation - ✔️✔️Safe and timely manner, evidence-based interventions,
collaboration, use community resources, coordinate care delivery , promote health and
health education, document care and any modifications
Evaluation - ✔️✔️Compare established outcomes with actual outcomes, identify any
roadblocks, modify pan, document evaluation of plan of care
Evidence based clinical decision making - ✔️✔️Evidence from research and evidence-
based theories, physical examination and assessment of patient, clinical expertise,
patient preferences and values
Complete data base - ✔️✔️Total health, complete health history/ full physical
examination, current and past health state and forms a baseline so changes can be
measured, ex primary care setting
Focused/problem centered data base - ✔️✔️Limited or short term, collect a mini
database or smaller in scope and more targeted, mainly for one problem one body
system
Emergency data base - ✔️✔️Rapid collection of crucial information complied
concurrently with lifesaving measures, diagnosis must be swift and sure, what did you
take Dan how much of it is was
