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subjective data=
what a person says about themselves
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objective data =
what you observe
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database=
objective and subjective data
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diagnostic reasoning
process of analyzing health data and drawing conclusions to identify diagnosis
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what is the nursing process?
- assessment
- diagnosis
- outcome identification
- planning
- implementation
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what key factors are involved in establishing a diagnosis
- interpret data (id clusters, make inferences)
- validate inferences
- compare clusters of cues
- identify related factors
- document diagnosis
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what is involved in the outcome id
- identify expected outcomes
- individualize to the person
- ensure outcomes are realistic and measurable
- include a time frame
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what is involved in planning
- establish priorities
- develop outcomes
- set time frame
- identify interventions
- document plan of care
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what is critical thinking in nursing
ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process used to ensure safe nursing practice and quality care
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critical thinkers strive to be
- clear, accurate, precise, logical, complete, significant and fair
- when listening, speaking, reading and writing
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what are the different levels of priorities
- 1st level = emergent ABC's
- 2nd level = next in urgency (pain, MS, urinary retention, abnormal labs)
- 3rd level = pt knowledge deficit, low self esteem, altered family process
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which health model does nursing follow?
holistic = concerned with the person as a whole (disease, social, spiritual)
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types of databases are
- complete (total health)
- episodic (problem centered)
- follow-up
- emergency database
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