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Nursing Process
1. Analyze/Assessment
2. Diagnosis
3. Evaluate/ outcome identification
4. Planning
5. Implementation
6. Evaluation
evidence-based practice
Interpret, validate, compare, identify, document.
SBAR
S: Situation
B: Background
A: Assessment
R: Recommendation
,First-Level Priority
emergent, life-threatening, and immediate, such as establishing an airway or
supporting breathing
Second-Level Priority
Next in urgency, requiring attention so as to avoid further deterioration
Example: acute pain, infection risk, elimination problems.
Third-Level Priority
Important to patient's health but can be addressed after more urgent problems
are addressed
4 Types of Data
Emergency, Follow-up, Focussed/Problem-Centered, Complete/Total Health.
Emergency Database
rapid collection of the database, often compiled concurrently with lifesaving
measures
,Follow-Up Database
used in all settings to monitor progress of short-term or chronic health problems
Example: heart failure (reevaluate medications, discuss coping strategies).
Focused or Problem-Centered Database
For limited or short term problem. Collect "mini" database, smaller in scope,
concerns mainly one problem, one cue complex, or one body system
Example: 2 days after surgery person suddenly has shortness of breath.
Complete (total health) Database
Complete health history and physical examination. It describes current and past
health state and forms a baseline against which all future changes can be
measured. Yields first diagnoses.
Evidence-Based Practice
clinical decision making that integrates the best available research with clinical
expertise and patient characteristics and preferences
Holistic Health
, the view that the mind, body, and spirit are interdependent and function as a
whole within the environment
Health Disparities
differences in the incidence, prevalence, mortality, and burden of diseases and
other health conditions among specific population groups
Cultural Competence
An understanding of how a patient's cultural background shapes his beliefs, values,
and expectations for therapy.
Linguistic competence
ability of caregivers and organizations to understand and effectively respond to
the linguistic needs of patients and their families in a health care encounter
Acculturation
The adoption of cultural traits, such as language, by one group under the
influence of another.
Assimilation