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Terms in this set (61)
-1850s: historical evolution of "research" evidence
began w/ Florence Nightingale
-best evidence from critical review of literature
Identify characteristics of
(research articles)
evidence-based practice.
-clinical expertise
-patient preferences
-clinical knowledge (physical assessment)
-attend to available cues (pick up on pieces of info pt.
gives you)
>ex: pt. alert and oriented when first came in, now
confused and clammy
-formulate diagnostic hypothesis (make a guess about
what is happening)
Identify characteristics of
>ex: pt. diabetic, maybe low blood sugar?
diagnostic reasoning.
-gather data relative to hypothesis
>ex: take blood sugar
-evaluate each hypothesis w/ new data collected to
arrive at final diagnosis
>ex: give orange juice and food, see if blood sugar
went up and plan worked
, -Assessment: collect all info, health hx, diet
assessment, risk assessment
-Diagnosis: cluster data, identify what pt. needs are
-Outcome Identification: if pt. has impaired skin
integrity, outcome is to have reduction/healing of
Identify characteristics of wound
nursing process. -Planning: set timeline, specific type of dressing,
reposition frequently
-Implementation: document what you do, coordinate
w/ other HC workers
-evaluation: see if it is working, sometimes they don't
work and need to come up w/ different plan
-novice: starting out in learning, uses rules to guide
performance
-competent: building on 2-3 years of clinical
experience, see actions in context of pt. goals or
Identify characteristics of plans
critical thinking. -proficient: adding time to experience, understands
pt. situation as a whole rather than individual parts -
apply long term goals
-expert: attained mastery of an area of learning,
performs clinical judgement using ituitive analysis
-complete (total health) database: all health hx,
physical assessment, creating database for initial
stage of care (ex: brand new pt, new hospital admit)
-focused (problem-centered) database: if pt. has
specific problem (ex: rash - do assessment/database
What different types of
for particular problem)
data should be gathered
-follow-up database: on a problem to see if it's gotten
during an assessment?
better or worse (ex: if rash pt. back, only assess to see
if improved or not)
-emergency database: assessment while giving life
saving measures (ex: pt. bleeding on ground, putting
pressure while asking questions about what happend)