Evidence based assesment

Question 1

______ is the collection of data about the individuals health state

Answer 1

Assessment

Question 2

———– Is What the patient says about himself/herself during history taking

Answer 2

Subjective data

Question 3

What you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination

Answer 3

Objective data

Question 4

Subjective data, objective data, with patients record and laboratory studies is referred to as_______

Answer 4

database

Question 5

from the _______ you make a clinical judgment or diagnosis about the individuals health state or response to actual or risk health problems and life processes, as well as diagnoses about higher levels of wellness.

Answer 5

database

Question 6

The purpose of assessment is to make a ______ or ___________

Answer 6

judgment; diagnoses

Question 7

___________ is the process of analyzing health data and drawing conclusions to identify diagnoses.

Answer 7

Diagnostic reasoning.

Question 8

Novice examiners often use a diagnostic process involving hypothesis forming and deductive reasoning. This Hypothetico-deductive process has four major components. What are they?

Answer 8

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.

Question 9

A ______ is a piece of information, a sign or symptom, or a piece of laboratory data.

Answer 9

cue

Question 10

What is a hypothesis?

Answer 10

A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation

Question 11

Validate the data you collect to make sure they are accurate… Why?

Answer 11

Identify missing pieces because it is an essential critical-thinking skill. Have an expert double check if you are unsure!

Question 12

What are the six phases of the nursing process?

Answer 12

1. assesment
2. diagnosis
3. outcome identification
4. Planning
5. Implementation
   6 Evaluation.

Question 13

Describe the differences between novice, competent, proficient, and expert nurses.

Answer 13

Novice- no experience and uses rules to guide performance

Competency- 2-3 years in similar clinical situations, in which you see actions in the context of arching goals or daily plans for patients

proficient nurses- understands a patient situation as a whole rather than as a list of tasks. You see long term goals

Expert- vault over the steps and arrive at a clinical judgment in one leap.

Question 14

Nursing Process

Describe Assesment

Answer 14

collect data: 
  review of the clinical record
  Health history
  Physical examination
  Functional assesment
  Review of the literature
Use evidence-based assesment techniques
Document relative data

Picture on page 3

Question 15

Nursing Process:

Describe Diagnosis

Answer 15

Compare clinical findings with normal and abnormal variation and developmental events

Interpret data
  Identify clusters or cues
  Make hypotheses
  Test hypotheses
  Derive diagnoses
Validate diagnoses
Document diagnoses

Page 3

Question 16

Nursing Process:

Describe Outcome identification

Answer 16

Identify expecteed outcomes
individualize to the person
culturally appropriate
realistic and measurable
include a timeline

Question 17

Nursing Process:

Describe Planning

Answer 17

Establish priorities
Develop outcomes
Set timelines for outcomes
identify interventions
integrate evidence based trends and research
document plan of care

Question 18

Nursing process:

Implementation

Answer 18

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 modification

Question 19

Nursing Process: Evaluation

Answer 19

• 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

Question 20

What are the 17 critical thinking skills?

Answer 20

1. Identifying assumptions
2. Identifying an organized and comprehensive approach to assessment
3. Validation
4. Distinguishing normal from abnormal
5. Making inferences
6. Clustering related cues
7. Distinguishing relevant from irrelevant
8. Recognizing inconsistencies
9. Identifying patterns
10. Identifying missing information
11. Promoting health
12. diagnosing actual and potential (risk) problems
    13.Setting priorities
13. Identifying patient-centered expected outcomes
14. Determing specific interventions
15. Evaluating and correcting thinking
    17 determining a comprehensive plan

**Details on each skill on pages 4-6

Question 21

_________ are clinical judgments about a persons response to an actual or potential health state

Answer 21

Nursing diagnoses

Actual diagnose- existing problems that are amenable to independent nursing interventions

Risk diagnoses- potential problems that an individual does not currently have but is particualrly vulnerable to developing

Wellnes diagnosis- focus on strengths and reflect an individuals transition to a higher level of wellness.

Question 22

______ are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing

Answer 22

first-level priority problems

Question 23

__________ next in urgency; requiring your prompt intervention to forestall further deterioration
Examples: mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security.

Answer 23

Second-level priority problems

** Important to look at table on page 5

Question 24

to asses for first level priority problems remember the “ABCs plus V”

What does the acronym refer to?

Answer 24

(A)irway problems
(B)reathing problems
(C)ardiac/circulation problems
(V)ital sign concerns

Question 25

__________ those that are important to the patients health but can be addressed after more urgent health problems are addressed

Answer 25

Third-level priority problems

Question 26

____________ are those in which the approach to treatment involves multiple disciplines

Answer 26

Collaborative problems

• certain physiologic complications in which nurses have the primary responsibility to diagnose the onset and monitor the changes in status

Question 27

______________ a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as the patient preferences and values, to make descisions about care and treatment

Answer 27

Evidence based practice

Question 28

___________includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. It yields the first diagnoses

Answer 28

complete (total health) database

- used in a primary care setting ( pediatric, family practice clinic, independent or group private practice etc)

Question 29

why do you screen for Pathology?

Answer 29

Because you are the first, and often the only, health professional to see the patient. You screen in order to refer the patient to another professional, to help the patient make decisions, and to perform appropriate treatments.

Question 30

Which type of database is for a limited or short-term problem?

Answer 30

Focused or Problem-Centered Database
-Here you collect a “mini” database, smaller in scope, and more targeted than the complete database. It concerns mainly one problem, one cue complex, or one body system.
Note: used in all settings

Question 31

This type of database is used in all settings to follow up short-term or chronic health problems

Answer 31

Follow-up Database

- status of any identified problem should be evaluated at regular and appropriate intervals

Question 32

________ database calls for a rapid collection of the data, often compiled concurrently with lifesaving measures.

Answer 32

Emergency database

Question 33

__________ views the mind, body, and spirit as interdependent and functioning as a whole within the environment.

Answer 33

Holistic health

• consideration of the whole person is the essence of holistic health.
• expanded to include culture, values, family, and social roles, self-care behaviors, job related stress, developmental tasks,and failures and frusturations of life