filtering information from different sources
assessment data
decide most important assessment data
relevant vs. irrelevant data - ANS-recognizing cues
what clinical judgment process includes:
organizing and linking recognized cues
consider cues in the context or the client history or situation
determine most concerning cues - ANS-analyzing cues
what clinical judgment process includes:
consider all possibilities about what is occuring in the client situation
, evaluating and ranking hypothesis according to priority
determine which explanations are most likely and most serious - ANS-prioritize
hypotheses
what clinical judgment process includes:
identifying expected outcomes and using hypotheses
consider which actual or potential evidence-based actions should be avoided or are
contradicted - ANS-generate solutions
what clinical judgment process includes:
actions - additional assessment, health teaching, documentation, request primary health
care provider prescriptions, performance of nursing skills, consultation with team
members - ANS-take action
what clinical judgment process includes:
comparing observed to our expected outcomes
determine what client assessment findings indicate improvement, decline, or no change
in the client's condition
decide if the selected nursing actions were effective, ineffective, or made no difference -
ANS-evaluate outcomes
5 steps of the nursing process - ANS-assessment, diagnosis, planning, implementation,
evaluation
gathering of data step of the nursing process - ANS-assessment
what part of the nursing process includes physiological, psychosocial, sociocultural,
spiritual, economic, and life-style factors - ANS-assessment
subjective data - ANS-patient's verbal descriptions of their health problems
objective data - ANS-information that is seen, heard, felt, or smelled by an observer;
signs
which of the following is subjective data about a patient?
a. history of heart disease
b. complaints of chest pain
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