Introduction to Health Assessment Final Exam.docx - Clinical judgement An interpretation or conclusion about a patient's needs concerns or health

Introduction to Health Assessment Final Exam.docx -...

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Clinical judgement An interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches or improvise new ones as deemed appropriate by the patient's response Nursing process includes Assessment, diagnostics, outcome identification, planning, implementation, evaluation Assessment First step. All decisions, diagnoses, treatments are based on data you gather. Subjective data What pt says about himself or herself during history taking Objective data Observed when inspecting (visual), percussing, palpating (touching), and auscultating (hearing) the pt during physical examination Noticing A nurse notices things about a pt in the context of the nurse's background and experience, context or environment, and knowing the pt. Looking for patterns that are consistent with previous experiences and uses that info to guide care Interpreting Process of assembling info to make sense of it. Types of reasoning patterns Analytic, Intuitive, Narrative Responding
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The implementation of actions and interventions based on pt needs. Nurse may not be able to judge effectiveness of the intervention before initiating it Reflecting Process of thinking and learning from experiences Reflection-in-action Happens in real time while are is occurring. Critical for development of knowledge and improvement in reasoning Reflection-on-action Happens after the pt care occurs Critical thinking Interpretation, analysis, evaluation, inference, and explanation skills needed. It's an active, orderly, well thought out reasoning process that guides a nurse in making clinical judgements Priority levels First level: emergent, life threatening and immediate (ABC) Second level: require prompt intervention to prevent further deterioration, such as acute pain, mental status change, abnormal labs, risk to safety Third level: important to pt's health, but can be addressed after more urgent problems Collaborative problems: approach to treatment involved multiple disciplines Pre-interaction phase Occurs before meeting the patient Orientation phase When the nurse and the pt meet and get to know each other
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Working phase When the nurse and the pt work together to solve problems and accomplish goals Termination phase Occurs at the end of a relationship BCMPAROS Biographical data, Chief complaint, Medical dx, Psyco social dx, ADLs, Review of Systems Extra heart sounds (S3 and S4) S3: produced by rapid filling, heard in early diastole, heard immediately after S2, "kentuck-y" S4: occurs at end of diastole, when ventricle resistant to filling, almost always abnormal, heard immediately before S1 Murmurs Gentle, blowing, swooshing sound that can be heard on chest wall Causes: o Velocity of blood increases (exercise, thryotoxicosis) o Viscosity of blood decreases (anemia) o Structural defects in valves, narrowed valve, incompetent valve o
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