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

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Clinical judgementAn 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 responseNursing process includesAssessment, diagnostics, outcome identification, planning, implementation, evaluationAssessmentFirst step. All decisions, diagnoses, treatments are based on data you gather.Subjective dataWhat pt says about himself or herself during history takingObjective dataObserved when inspecting (visual), percussing, palpating (touching), and auscultating (hearing) the pt during physical examinationNoticingA 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 careInterpretingProcess of assembling info to make sense of it.Types of reasoning patternsAnalytic, Intuitive, NarrativeResponding
The implementation of actions and interventions based on pt needs. Nurse may not be able to judge effectiveness of the intervention before initiating itReflectingProcess of thinking and learning from experiencesReflection-in-actionHappens in real time while are is occurring. Critical for development of knowledge and improvement in reasoningReflection-on-actionHappens after the pt care occursCritical thinkingInterpretation, analysis, evaluation, inference, and explanation skills needed. It's an active, orderly, well thought out reasoning process that guides a nurse in making clinical judgementsPriority levelsFirst 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 safetyThird level: important to pt's health, but can be addressed after more urgent problemsCollaborative problems: approach to treatment involved multiple disciplinesPre-interaction phaseOccurs before meeting the patientOrientation phaseWhen the nurse and the pt meet and get to know each other
Working phaseWhen the nurse and the pt work together to solve problems and accomplish goalsTermination phaseOccurs at the end of a relationshipBCMPAROSBiographical data, Chief complaint, Medical dx, Psyco social dx, ADLs, Review of SystemsExtra 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 S1MurmursGentle, blowing, swooshing sound that can be heard on chest wallCauses:oVelocity of blood increases (exercise, thryotoxicosis)oViscosity of blood decreases (anemia)oStructural defects in valves, narrowed valve, incompetent valveo

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