Jarvis-Physical Examination & Health Assessment Study Guide & Lab_ Chapter 1|ALREADY GRADED A|

Evidence-based assessment discusses the characteristics of: 1. evidence-based practice 2. diagnosis reasoning 3. the nursing process and 4. critical 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