Exam 1 Notes.docx - Module 1 Chapter 1 Evidence Based...

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51 Module 1: Chapter 1: Evidence Based Assessment Assessment: Point of Entry in an Ongoing Process Subjective data What patient says about himself or herself during history taking Objective data Observed when inspecting, percussing, palpating, and auscultating patient during physical examination Database Formed from these elements, plus patient’s record and laboratory studies Steps of the Nursing Process: 1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation Nursing process: Critical Thinking systematically Assessment Diagnosis / analysis Plan Interventions Evaluations Nursing Process: Assessment Collection of data from multiple sources Review of clinical record Interview Health history Physical examination Functional assessment Activities of daily living Cultural and spiritual assessment Consultation Review of the literature Nursing Process: Diagnosis Interpretation of data by identifying clusters of cues so as to make inferences Compare clusters of cues with definitions and defining characteristics Validation of inferences based on findings Identify related factors Document the diagnosis Nursing Process: Outcome Identification Identify expected outcomes related to patient individualization Ensure outcomes are realistic and measurable Specify short-term and long-term goal measurement criteria Nursing Process: Planning Establish priorities based on meeting identified patient care goals
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51 Develop outcomes and set time frames for meeting proposed outcomes Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient Document plan of care Question The nurse has a “hunch” that the patient’s elevated blood pressure is due to pain level; however, the patient received blood pressure and pain medication 45 minutes ago. What should the nurse consider in regards to this hunch? 1. Research supports that the pain and blood pressure medications will take 30 minutes to become effective. The nurse should wait until the next prescribed time and reevaluate pain level 2. The nurse should consider consulting with the pain management team to evaluate the effectiveness of the pain medication regimen. 3. The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practices 4. The nurse should administer pain medication based on the hunch Correct Answer: 2 Nursing Process: Implementation Determine patient readiness and involve patient(s) in health care process Review planned interventions with interdisciplinary health care team members to facilitate collaborative effort Utilize principles of delegation, being mindful of supervision and evaluation Counsel person and significant others Refer for continuing care Document care provided Nursing Process: Evaluation Refer to established outcomes
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  • Fall '16
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