Medical diagnosis - answer focuses on a disease process (ex: hypertension)
Nursing diagnosis - answer-individuals response to disease or risk (subjective and
objective data and their response)
-foundation for care for patient
Steps of nursing process - answer-Assessment
-Diagnosis
-Outcome identification
-Planning
-Implementation
-Evaluation
(ADOPIE)
What is health assessment? - answer-data collection, data base, diagnostic or clinical
reasoning, *starting point for nursing process
What is subjective data? - answer-data given from the subject (what the patient says)
What is objective data? - answer-what you can measure or observe (ex: hearing
abnormal lung sounds)
Example of how something can be subjective and objective - answer-patient says they
think they have a fever, you check their temp and they do indeed have a fever
Type of data - answerPhysical: 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:
4 types of dataabse - answer-Complete
-Focused, Problem-centered, episodic
-Follow up
-Emergency
Complete total health database - answer-complete health history and full physical
examination
-current and past health state
, -first diagnosis
Episodic or problem-centered database - answer-short term problem and would collect
a "mini database" more focused than complete
-*single problem
-history and examination follow reason for visit
Follow-up database - answer-note changes that have occurred, evaluate whether
problem is getting better or worse
-broke arm, went back for cast
Emergency database - answer-rapid collection of data that must be comprehensive
concurrently with lifesaving measures
-ex: obstruction in airway
First-level priority - answer-life threatening and immediate
-ex: BP is 40, someone is not responding or breathing
Second-level priority - answer-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
Third-level priority - answer-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
Collaborative problems - answer-treatment involving multiple disciplines
-ex: taking care of stroke patient who needs PT and SP
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 - answerA
-Palpation deep and light
-When would you palpate tender areas? - answer-deep: 4 in, light 1 in
-last
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