Nursing Assessment and Diagnostic Process

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Questions and Answers

What is the purpose of a follow-up database in nursing?

  • To gather crucial data for emergency situations
  • To provide a complete health history for a new patient
  • To assess the impact of medications over time
  • To evaluate the status of previously identified problems (correct)

How does the novice nurse approach patient situations?

  • Evaluates the patient as a whole rather than tasks
  • Uses an intuitive grasp of the clinical situation
  • Conducts assessments based on personal experiences
  • Employs rules to guide performance and competency (correct)

What characterizes the focused (or problem-centered) database in nursing?

  • It prioritizes emergencies and life-threatening situations
  • It evaluates multiple chronic health issues simultaneously
  • It is used for a limited or short-term problem (correct)
  • It includes all patient history from birth onwards

What defines first-level priority problems in nursing?

<p>They are emergent and life-threatening requiring immediate attention (B)</p> Signup and view all the answers

What is critical thinking in the context of nursing assessment?

<p>Sound diagnostic reasoning and clinical judgment (B)</p> Signup and view all the answers

What is primarily included in the subjective data during patient assessment?

<p>Opinions and statements from the patient (C)</p> Signup and view all the answers

Which priority level includes problems that can be addressed after more urgent issues?

<p>Third-level priority problems (C)</p> Signup and view all the answers

What is the primary purpose of assessment in the nursing process?

<p>To make a judgment or diagnosis (B)</p> Signup and view all the answers

Which of the following is NOT one of the six phases of the nursing process?

<p>Observation (D)</p> Signup and view all the answers

What characterizes evidence-based practice in nursing?

<p>It uses a combination of research evidence, clinical expertise, and patient preferences. (A)</p> Signup and view all the answers

Which term refers to the totality of information available about a patient during assessment?

<p>Database (B)</p> Signup and view all the answers

What is the first step in the nursing process?

<p>Assessment (A)</p> Signup and view all the answers

Which method is NOT part of collecting objective data about a patient during assessment?

<p>Patient interviews (C)</p> Signup and view all the answers

Flashcards

Complete Database

A complete health history and a full physical examination, resulting in the first diagnoses.

Focused Database

Used when focusing on a specific problem or condition, gathering smaller, targeted information.

Follow-up Database

Evaluates the status of a problem at regular intervals, tracking both short-term and chronic issues.

Emergency Database

Rapidly gathered data during emergencies, prioritizing critical information for life-saving interventions.

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Critical Thinking in Nursing

A process of thinking critically about assessment data, making sound diagnoses, and prioritizing patient needs.

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Assessment in Nursing

Gathering information about a patient's health, including what they tell you and what you observe.

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Subjective Data

Information provided by the patient, such as their symptoms or feelings.

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Objective Data

Information gathered by the healthcare provider through observation, examination, and tests.

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Database

A collection of all the information about a patient's health, including subjective data, objective data, and medical records.

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Diagnosis

The final conclusion about a patient's health condition based on the assessment.

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Evidence-Based Practice

A systematic way of providing care using research evidence, clinical expertise, patient preferences, and values.

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Focused Assessment

A focused assessment that is limited to a specific problem or concern.

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Study Notes

Assessment and Diagnostic Process

  • Assessment involves collecting subjective and objective data about a patient's health.
  • Subjective data are provided by the patient.
  • Objective data are obtained through observation, palpation, percussion, and auscultation.
  • The database includes subjective and objective data, medical records, and lab results.
  • Data clustering and validation are important for accurate assessment.

Nursing Process

  • The nursing process involves six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
  • It's an interactive process.
  • Practitioners might move between phases.
  • Nurses' experience levels affect how they apply the process.

Novice Nurse

  • Novice nurses lack experience, relying on rules and procedures.
  • Their goal is proficiency.

Proficient Nurse

  • Proficient nurses see the whole patient situation rather than individual tasks.
  • They recognize patterns in assessment data.
  • They act without conscious labeling.

Expert Nurse

  • Expert nurses have intuitive understanding of clinical situations.
  • They identify accurate solutions quickly.
  • Critical thinking and clinical judgement are key.

Priority Problems

  • First-level priority problems are emergent, life-threatening, and immediate (e.g., airway management, breathing support).
  • Second-level priority problems require prompt intervention to prevent further decline (e.g., mental status changes, acute pain).
  • Third-level priority problems are important but can be addressed later (e.g., family coping, lack of knowledge)

Evidence-Based Assessment

  • Evidence-based practice combines research, practitioner expertise, patient values, and knowledge to inform treatment decisions.
  • Four types of databases are complete/total, focused, follow-up, and emergency.
  • Complete databases include a complete health history and physical examination.
  • Focused databases are for specific, limited issues.
  • Follow-up databases track identified problems over time.
  • Emergency databases prioritize rapid data collection in critical situations.

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