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Follow up data base - ️️Short term/ chronic problems, problems should be evaluated at regular and appropriate intervals What has changed, worse/better, coping strategies used Evidenced based practice - ️️Patients deserve to be treated with most current and best practice techniques Syst...

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Nur 230 exam 1
Follow up data base - ✔️✔️Short term/ chronic problems, problems should be
evaluated at regular and appropriate intervals
What has changed, worse/better, coping strategies used

Evidenced based practice - ✔️✔️Patients deserve to be treated with most current and
best practice techniques
Systematic approach to practice that emphasizes the use of best evidence in
combination with clinicians experience as wel as the patients preferences and values

Diagnosis - ✔️✔️Compare findings that are normal and abnormal, and developmental
events, interpret data, identify cluster of clues, make hypotheses and test it, derive
diagnosis, validate and document diagnosis

Assessment - ✔️✔️Collect data subjective and objective, it is an ongoing processes
not a one time thing
Review of the clinical record, health history, physical examination, functional
assessment, risk assessment, review of the literature , use evidence-based assessment
techniques, document relevant data

Subjective data - ✔️✔️What the patients says about their self during history taking, or
what a close family member or friend say, cultural/spiritual , mental status ,

Objective data - ✔️✔️Observations made during physical examination, general survey,
vital signs, head-to-toe assessment

Comprehensive "admission assessment" - ✔️✔️Health history and physical exam,
enables complete picture of patients health status

Episodic/focused "shift assessment" - ✔️✔️A comprehensive asses that focuses more
on a specific things

Emergency assessment - ✔️✔️Not going to take the time to do comprehensive

Follow-up assessment - ✔️✔️What changed, better/worse, what coping strategies
used

physical examination - ✔️✔️Inspection, palpitation, percussion, auscultation

Nursing process - ✔️✔️Assessment, diagnosis, planning, implementation, evaluation
(ADPIE)

, Outcome identification - ✔️✔️Identify expected outcomes, individualize for patient,
culturally appropriate, realistic and measurable and have a time frame

Planning - ✔️✔️Establish priorities, develop outcomes, set timelines for outcomes,
identify interventions, integrate evidence based trends/research, document plan of care,
development outcomes, identity interventions, document plan of care

First level priority problem - ✔️✔️Are emergent, life-threatening, or immediate (ABCV)
airway, breathing cardiac/cardiovascular probs, vital sign concerns

Second level priority problem - ✔️✔️Next in urgency, prompting you to forestall further
deterioration (mental changes, acute pain, urinary elimination, abnormal lab value, risk
of infection

Third level problems - ✔️✔️Important to patients health, but can be addressed later or
after more urgent steps taken care of, more long term, response to treatment expected
to take more time

Collaborative problems - ✔️✔️Approach to treatment involves multiple disciplines
nurse's diagnosis the onset and monitor the changes in status

Implementation - ✔️✔️Safe and timely manner, evidence-based interventions,
collaboration, use community resources, coordinate care delivery , promote health and
health education, document care and any modifications

Evaluation - ✔️✔️Compare established outcomes with actual outcomes, identify any
roadblocks, modify pan, document evaluation of plan of care

Evidence based clinical decision making - ✔️✔️Evidence from research and evidence-
based theories, physical examination and assessment of patient, clinical expertise,
patient preferences and values

Complete data base - ✔️✔️Total health, complete health history/ full physical
examination, current and past health state and forms a baseline so changes can be
measured, ex primary care setting

Focused/problem centered data base - ✔️✔️Limited or short term, collect a mini
database or smaller in scope and more targeted, mainly for one problem one body
system

Emergency data base - ✔️✔️Rapid collection of crucial information complied
concurrently with lifesaving measures, diagnosis must be swift and sure, what did you
take Dan how much of it is was

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