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1. Medical diagnosis: focuses on a disease process (ex: hypertension)
2. Nursing diagnosis: -individuals response to disease or risk (subjective and
objective data and their response)
-foundation for care for patient
3. Steps of nursing process: -Assessment
-Diagnosis
-Outcome identification
-Planning
-Implementation
-Evaluation
(ADOPIE)
4. What is health assessment?: -data collection, data base, diagnostic or
clinical reasoning, *starting point for nursing process
5. What is subjective data?: -data given from the subject (what the patient
says)
6. What is objective data?: -what you can measure or observe (ex: hearing
abnormal lung sounds)
7. Example of how something can be subjective and objective: -patient
says they think they have a fever, you check their temp and they do indeed
have a fever
8. Type of data: Physical: what am i seeing or smelling
Cognitive: patients mental status, behavior, mood
Psychosocial: who takes care of them at home, family situation
Behavioral:
Environmental: "where do you work" "are you by a farm"
Developmental:
9. 4 types of dataabse: -Complete
-Focused, Problem-centered, episodic
-Follow up
-Emergency
10. Complete total health database: -complete health history and full
physical examination
, Health Assessment Quiz 1
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-current and past health state
-first diagnosis
11. Episodic or problem-centered database: -short term problem and would
collect a "mini database" more focused than complete
-*single problem
-history and examination follow reason for visit
12. Follow-up database: -note changes that have occurred, evaluate whether
problem is getting better or worse -broke arm, went back for cast
13. Emergency database: -rapid collection of data that must be
comprehensive concurrently with lifesaving measures
-ex: obstruction in airway
14. First-level priority: -life threatening and immediate
-ex: BP is 40, someone is not responding or breathing
15. Second-level priority: -requires attention to avoid further deterioration
-ex: if someone is confused as to where they are at (hospital) needs to be
addressed to avoid further confusion
16. Third-level priority: -can be addressed after more urgent problems are
addressed
-ex: BP is slowly creeping up but needs to be watched while 1st and 2st
priorities are taken care of
17. Collaborative problems: -treatment involving multiple disciplines
-ex: taking care of stroke patient who needs PT and SP
18. A 52-year-old male patient is admitted with a new diagnosis of colon
cancer. The nurse conducts which type of assessment on his
admission?
A. A complete assessment
B. A problem-based health assessment
C. A follow-up data base
D. A screening assessment: A
19. 4 assessment techniques: -Inspection
-Palpation
-Percussion