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Summary Exam 1 Key Concepts.docx Exam #1 Key Concepts Ch. 1 Evidence-Based Assessment: Please review powerpoint and follow along with the book. 1) Understand subjective vs objective data. a) Subjective Data- The data collected that the patient (subject) $7.49
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Summary Exam 1 Key Concepts.docx Exam #1 Key Concepts Ch. 1 Evidence-Based Assessment: Please review powerpoint and follow along with the book. 1) Understand subjective vs objective data. a) Subjective Data- The data collected that the patient (subject)
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Snhu
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Southern New Hampshire University
Exam 1 Key C Exam #1 Key Concepts Ch. 1 Evidence-Based Assessment: Please review powerpoint and follow along with the book. 1) Understand subjective vs objective data. a) Subjective Data- The data collected that the patient (subject) told you. This can be any information from the patients ...
exam 1 key conceptsdocx exam 1 key concepts ch 1 evidence based assessment please review powerpoint and follow along with the book 1 understand subjective vs objective data a subjectiv
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Exam #1 Key
Concepts
Ch. 1 Evidence-Based Assessment: Please review powerpoint and follow along with the book.
1) Understand subjective vs objective data.
a) Subjective Data- The data collected that the patient (subject) told you. This can be any
information from the patients health history or the patients pain level. Ex. The patients states “I
made the appointment today because I have been experiencing pain in my knee.” Documenting
the patient stated the location and pain. You would then follow PQRST.
b) Objective Data- The data collected that you observe from the patient. This would be any
markings, tattoos, anything that can be measured or seen by you the nurse. Ex. The patient has a
node on his/her arm. They are AAOx4, temperature is 98.7, BP is 120/80. You examined all of
these things while assessing the patient.
2) Understand the database.
3) Understand diagnostic reasoning---- is the process of analyzing health data and drawing conclusions
to identify diagnoses. Novice examiners most often use a diagnostic process involving hypothesis
forming and deductive reasoning. This hypothetico-deductive process has four major components: (1)
attending to initially available cues; (2) formulating diagnostic hypotheses; (3) gathering data relative
to the tentative hypotheses; and (4) evaluating each hypothesis with the new data collected, thus
arriving at a final diagnosis. A cue is a piece of information, a sign or symptom, or a piece of
laboratory or imaging data. A hypothesis is a tentative explanation for a cue or a set of cues that can
be used as a basis for further investigation. (Jarvis, PG 40)
4) Understand the nursing process. (ADPIE)
a) Assessment- -collect as much data, physical findings, historical information, verbal and non-
verbal observations, medical records, self-care abilities, psycho-social implications (objective and
subjective data needs to be collected)
b) Diagnosis--Nursing diagnosis, not medical diagnosis--the only acceptable diagnosis from the
North American Nursing Diagnosis Association (NANDA) Identification of a disease or
condition by scientific evaluation of physical signs and symptoms.
Outcome Identification 1) Identify expected outcomes 2) individualize to the person 3) culturally
appropriate 4) realistic and measureable 5) include a timeline
c) Planning- 1) Establish priorities 2) develop outcomes 3) set timelines for outcomes 4) identify
interventions 5) integrate evidence-based trends and research 6) document plan of care
d) Implementation- The nurse will now implement the plan that he/she developed to care for the
patient. 1) Implement in a safe and timely manner 2) use evidence-based interventions 3)
collaborate with colleagues 4) use community resources 5) coordinate care delivery 6) provide
heath teaching and health promotion 7) document implementation and any modification
e) Evaluation- The process that will be look at carefully to Determine if the goals or intended
outcomes were met. This can also happen after ----1) Progress toward outcomes 2) conduct
systematic ongoing criterion-based interventions 3) include patient and significant others 4) use
ongoing assessment to revise diagnoses, outcomes, plan 5) disseminate results to patient and
family
5) Understand priority setting (first, second, and third level).
, a) First level Priority- ABC’s, Airway, Breathing, Circulation, first level priority is an emergency
level or life-threatening emergency. This level will be your priority before all other levels.
b) Second Level Priority-The nurse wants to make sure to see this patient next to make sure of no
further issues or further deterioration. Examples of further deterioration meaning worsening
symptoms. Mental status change, acute pain, acute urinary elimination problems, untreated
med problems, abnormal labs, risks of infection.
c) Third Level Priority- All other problems that can be treated after the first and second level
priority, these would be problems like Lack of knowledge, mobility problems, family
coping
6) Understand evidence-based assessment- research evidence, clinical expertise, clinical knowledge
(physical assessment), and patient values/preferences
Ch. 2: Cultural Assessment: Please review powerpoint and follow along with the book.
Understand the difference between religion and spirituality
o Spirituality- broader term that encompasses something larger than one’s own
existence with a belief in transcendence
o Religion- refers to an organized system of beliefs as a shared experience that can assist
in meeting one’s individual spiritual needs
Understand race and ethnicity and how does this relate the health care?
o Race- social construct referring to a group of people who share similar
physical characteristics
o Ethnicity- Social group with shared traits (geographic origin, religion, language, values,
food preferences), Ethnic identity: Self-identification with a particular ethnic group.
o These concept relate to health care because they are apart of the cultural assessment
process. These concepts can help you as a nurse to produce an effective health
assessment data collection.
Understand acculturation and acculturative stress
o Acculturation- Process of adopting culture and behavior of the majority culture
o Acculturative stress- losses and changes that occur when adjusting to or integrating a
new system of beliefs, routines, and social roles (page 14)
Understand becoming a culturally competent practitioner
o A culturally competent practitioner makes sure they are: Culturally sensitive-
Caregivers possess basic knowledge and understanding, Culturally appropriate-
Caregivers apply knowledge to improve health outcomes, Culturally competent-
Caregivers apply a universal concept of understanding to all contextual aspects of care,
Cultural care- Provision of health care across cultural boundaries in consideration of
context.
Understand cultural assessment and spiritual assessment.
o Cultural assessment can include Heritage, health practices and communication, Family
roles and social orientation, nutrition and pregnancy, birth/childrearing,
Spirituality/religion, death, and health providers, the nurse should remember not all
culture is universal.
o Spiritual assessment- you want to ask open-ended questions. “do you have any spiritual
and cultural preferences? Do you have any beliefs or values that are important to you?”
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