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CHAPTER ONE: EVIDENCE-BASED ASSESSMENT (2)
1. What is evidence-based assessment? What are benefits to utilizing?
a. Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences
b. Clinical decision making = best evidence from literature review + patient’s own preference + clinician’s experience +
physical exam
2. Define Subjective Data and provide examples.
a. What the subject says
b. Ex. “8/10”, “headache”, “stomach pain”
3. Define Objective Data and provide examples.
a. What the nurse observes
b. Ex. red rash on leg, lesions on skin, slurred speech
4. What is diagnostic reasoning and how is used in physical assessment/health assessment?
a. Process of analyzing heath data and drawing conclusions to identity diagnoses
b. Hypothesis forming and deductive reasoning
5. What is the use of nursing process in clinical judgement?
a. ADPIE
i. Assessment – collect data
ii. Diagnosis – figure out what’s wrong
iii. Planning – make plans, set goals
iv. Implementation – do the steps to get to the end goal
v. Evaluate – reassess what happened, fix anything if needed, make a new goal
6. What are first-level, second level, and third-level priority problems?
a. First level priority – emergent, life threatening, and immediate
i. s (airway, breathing, circulation)
b. Second level priority – requiring your prompt intervention to forestall further deterioration
i. Mental status change, acute pain, risks of infection, risk to safety
c. Third level priority - important to patient’s health but can be attended to after more urgent health problems are
addressed
i. Treat these problems are long term, and respond to treatment is expected to take more time
ii. Require a collaborative effort between the patient and health care professionals
iii. Lack of knowledge, immobility
7. What are steps to setting priorities during the interview process?
a. Complete health history, including allergies, medications, current medical problems, and reason for visit
b. Determine whether any problems are related and set priorities.
8. What are four types of databases? Provide an example of each.
a. Complete (Total Health) Database – complete health history and a full physical examination, current and past
health state
b. Focused or Problem-Centered Database – for limited or short-termed problem, mini database, more targeted to
one specific problem
c. Follow-Up Database – identified problems should be evaluated at regular and appropriate intervals, following up
with issues, short term, and chronic issues
d. Emergency Database – urgent, rapid collection of crucial information, usually happens with lifesaving measures
i. Ex overdose patient, data: “what did you take? How long ago?”
CHAPTER TWO: CULTURAL ASSESSMENT (2)
, 1. Why is it important for nurses to practice or have cultural competence when completing physical/health assessment?
a. Increased understanding of cultural diversity by being self-aware and knowledgeable about one’s own culture
b. Awareness is an interactive and ongoing process for members of the health care profession
c. Performing cultural self-assessment is an integral part of becoming culturally competent
2. What is cultural assessment?