-
Definition: Assessment
The collection of data about an individual's health state.
-
Definition: Biomedical Model
The Western European/North American tradition that views health as the absence of disease.
-
Definition: Complete Database
A complete health history and full physical examination.
-
Definition: Critical Thinking
Simultaneously problem-solving while self-improving one's own thinking ability.
-
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.
-
Definition: Emergency Database
Rapid collection of the database, often compiled concurrently with lifesaving measures.
-
Definition: Environment
The total of all the conditions that make up the surrounding and influence the development of a person.
-
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.
-
Definition:Focused Database
One used for a limited or shot-term problem; Concerns mainly one problem, one cue complex, or one body system.
-
Definition:Follow-up Database
Used in all settings to monitor progress on short-term or chronic health problems.
-
Definition:Holistic Health
The view that the mind, body, and spirit are interdependent and function as a whole within the environment.
-
Definition:Medical Diagnosis
Used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system.
-
Definition:Nursing Diagnosis
Used to evaluate the response of the whole person to actual or potential health problems.
-
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
-
Definition:Objective Data
What the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination.
-
Definition:Prevention
Any action directed toward promoting health and preventing the occurrence of disease.
-
Definition:Subjective Data
What the person says about him or herself during history taking.
-
Definition:Wellness
A dynamic process and view of health; a move toward optimal functioning.
-
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
-
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
-
Concept: Nursing Process- (3) Outcome Identification
- Identify expected outcomes
- Individualize the the person
- Culturally appropriate
- Realistic and measurable
- Incluse a time line
-
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
-
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
-
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
|
|