Nursing Assessment 3009 Chapter 1

  1. Definition: Assessment
    The collection of data about an individual's health state.
  2. Definition: Biomedical Model
    The Western European/North American tradition that views health as the absence of disease.
  3. Definition: Complete Database
    A complete health history and full physical examination.
  4. Definition: Critical Thinking
    Simultaneously problem-solving while self-improving one's own thinking ability.
  5. Definition: Diagnostic Reasoning
    • A method of collecting and analyzing clinical information 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 hypothesis with the new data collected.
    • 5-Arriving at a final diagnosis.
  6. Definition: Emergency Database
    Rapid collection of the database, often compiled concurrently with lifesaving measures.
  7. Definition: Environment
    The total of all the conditions that make up the surrounding and influence the development of a person.
  8. Definition:Evidence-Based Practice
    EBP-A systematic approach emphasizing the best research evidence, the clinician's experience, patient preference and values, physical examination and assessment.
  9. Definition:Focused Database
    One used for a limited or shot-term problem; Concerns mainly one problem, one cue complex, or one body system.
  10. Definition:Follow-up Database
    Used in all settings to monitor progress on short-term or chronic health problems.
  11. Definition:Holistic Health
    The view that the mind, body, and spirit are interdependent and function as a whole within the environment.
  12. Definition:Medical Diagnosis
    Used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system.
  13. Definition:Nursing Diagnosis
    Used to evaluate the response of the whole person to actual or potential health problems.
  14. Definition:Nursing Process
    • A method of collecting and analyzing clinical information with the following components:
    • 1-Assessment
    • 2-Diagnosis
    • 3-Outcome of Identification
    • 4-Planning
    • 5-Implementation
    • 6-Evaluation
  15. Definition:Objective Data
    What the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination.
  16. Definition:Prevention
    Any action directed toward promoting health and preventing the occurrence of disease.
  17. Definition:Subjective Data
    What the person says about him or herself during history taking.
  18. Definition:Wellness
    A dynamic process and view of health; a move toward optimal functioning.
  19. Concept: Nursing Process- (1) Assessment
    • Collect data
    •     Review of the clinical record
    •     Health History
    •     Physical Examination
    •     Functional Assessment
    •     Risk Assessment
    •     Review of Literature
    • Use evidence based assessment techniques
    • Document relevant data
  20. Concept: Nursing Process- (2) Diagnosis
    • Compare clinical findings with normal and abnormal variation and developmental events
    • Interpret Data
    •     ID clusters or cues
    •     Make Hypotheses
    •     Test Hypotheses
    •     Derive Diagnoses
    • Validate Diagnoses
    • Document Diagnoses
  21. Concept: Nursing Process- (3) Outcome Identification
    • Identify expected outcomes
    • Individualize the the person
    • Culturally appropriate
    • Realistic and measurable
    • Incluse a time line
  22. Concept: Nursing Process- (4) Planning
    • Establish priorities
    • Develop outcomes
    • Set timelines for outcomes
    • ID interventions
    • Integrate evidence-based trends and research
    • Document plan of care
  23. Concept: Nursing Process- (5) Implementation
    • Implement in a safe and timely manner
    • Use Evidence-based interventions
    • Collaborate with colleagues
    • Use community resources
    • Coordinate care delivery
    • Provide health teaching and health promotion
    • Document implementation and any modification
  24. Concept: Nursing Process- (6) Evaluation
    • Progress toward outcomes
    • Conduct systemic, ongoing, criterion-based evaluation
    • Include patient and significant others
    • Use ongoing assessment to revise diagnoses, outcomes, plan
    • Disseminate results to patient and family
Card Set
Nursing Assessment 3009 Chapter 1
Vocabulary and Concepts Chapter 1 Assessment