Update 2024/2025
Subjective Data - ✔️✔️what pt says abt himself or herself during history taking
objective data - ✔️✔️Observed when inspecting, percussing, palpating, and auscultating
patient during physical examination
database - ✔️✔️subjective data, objective data, and patient's record and laboratory
studies
clinical judgment - ✔️✔️diagnosis abt the individual's health state, response to actual or
potential health problems, and life processes.
diagnostic reasoning - ✔️✔️- is the process of analyzing health data and drawing
- conclusions to identify diagnoses.
hypothetic deductive process / steps to diagnostic reasoning - ✔️✔️1) attending to initially
available cues
2) formulating diagnostic hypotheses
3) gathering data relative to the tentative hypotheses
4) evaluate each hypothesis with the new data collected, thus arriving at a final diagnosis
Nursing process phases - ✔️✔️1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation
ADOPIE
,Assessment - ✔️✔️- Collect data
- Review of clinical record
- Interview
- Health history
- Physical examination
- Functional assessment
- Cultural and spiritual assessment
- Consultation
- Review of literature
Diagnosis - ✔️✔️- Interpret (Interpret data: Identify clusters of cues, Make inferences)
- Validate (Validate inferences)
- Compare (Compare clusters of cues with
definitions and defining characteristics)
- Identify (Identify related factors)- Document (Document the diagnosis)
Outcome Idenetification - ✔️✔️- Identify expected outcome
- Individualize to the person
- Identify culturally appropriate outcomes
- Establish realistic and measurable outcomes
- Develop a timeline
Planning - ✔️✔️- Establish priorities
- Develop outcomes
- Set timelines
- Identify interventions
- Integrate evidence-based trends and research
- Document plan of care
, Implementation - ✔️✔️- Determine patient readiness
- Review planned interventions
- Collaborate with other team members
- Supervise by delegating appropriate
responsibilities
- Counsel person and significant others
- Involve person in healthcare
- Refer for continuing care
- Document care provided
Evaluation - ✔️✔️- Refer to established outcomes
- Evaluate individual's condition and compare
actual outcomes with expected outcomes
- Summarize results of evaluation
- Identify reasons for failure to achieve
expected outcomes
- Take corrective action to modify plan of care
- Document evaluation in plan of care
first-level priority problems - ✔️✔️- emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing
- CABs (Cardiac/circulation + Airway, Breathing)
- V (Vital Signs)
second-level priority problems - ✔️✔️- those that are next in urgency requiring your
prompt intervention to forestall further deterioration. (mental status change, acute pain,
acute urinary elimination problem, untreated medical problems, abnormal lab test results
- requires prompt action
- episodic or problem-centered database