Week 1; Health Assessment .docx - Week 1 Critical Thinking...

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Week 1 Critical Thinking and Evidence-Informed Assessment ------> Chapter 1 Allows timely, relevant, and appropriate nursing and healthcare We must be able to accurately describe assessment health findings to family, patients and other members of the interprofessional team physical, cognitive, psychomotor and behavioural data is needed for an accurate analysis of a patient's state Assessment: The collection of data about an individual’s health state Through this you will gather: a. Subjective Data : what the person says/tells you b. Objective Data: what you gather from the person using your senses Together, subjective and objective data, as well as test results and physical examination, come together to form a Database. From the database you can make clinical judgement or diagnosis about the individuals state of health. Diagnostic Reasoning: This is where you start to separate the data from the important data It is the process of analyzing health data and drawing conclusions do identify diagnoses The 4 components include: a. Attending to initially available cues b. Formulating diagnostic hypotheses c. Gathering data relative to the tentative hypotheses d. Evaluating each hypothesis with new data collected, thus arriving at the final diagnosis Cue: A piece of information, a sign or symptom, or a piece of laboratory data Hypothesis: A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation When trying to diagnose a patient: Try and group together the assessment data that appear to be casual or associated As you evaluate, look for gaps in the information/data All missing information is an essential critical thinking skill and can be the missing piece that you need
Always validate the data to make sure it is correct and accurate. You can do this by repeating something such as blood pressure if you are not sure Critical Thinking and Diagnostic Process: Nursing Process: A systematic method of planning and providing patient care organized around a series of phrases that integrate evidence-informed practice and critical thinking The 5 Phases are: 1. Assessment: collect data, organize data, validate data, document data 2. Nursing diagnosis: analyze data, identify health problems, risks and strengths, formulate diagnostic statements 3. Planning: prioritize problems and diagnoses, formulate goals and designed health outcomes. Identify nursing interventions 4. Implementation: reassess the patient, determine the nurse’s need for assistance, implement nursing interventions, supervise delegated care, document nursing activities 5. Evaluation : collect data related to outcomes, complete data with outcomes, relate nursing actions to patient goals/outcomes, draw conclusions about problem, continue, modify and or end patient’s care plan This is how nurses assess before acting In the clinical area there is no specific order to the 5 steps. It is a multidimensional thinking process With time, you will be able to apply these skills in a rapid, dynamic, interactive way

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