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| the collection of data about the individual's health state |
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| western tradition of medicine, views health as the absence of disease |
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| diagnosis based on the data base |
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| see relationships among the data |
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| those problems in which the approach to treatment involves multiple disciplines |
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| thinking about your thinking while you're thinking in order to make your thinking better, or simultaneously problem-solving while self-improving your thinking ability |
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| a piece of information, diagnostic data, sign, or symptom that provides insight |
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| Database (complete or total, episodic or problem centered, follow up, emergency |
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Definition
| the whole patient record used to make diagnosis. An episodic or problem centered database is a partial record based on the problem at hand. A follow up database identifies problems that should be addressed at regular intervals (like diabetes). An emergency database is the material available about the patient in the event of an emergency. |
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| the process of analyzing health data and drawing conclusions to identify diagnoses, is based on the scientific method |
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| identify and manage known risk factors for the individual's age-group and cultural status |
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| view of health that takes the consideration of the whole person into account |
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| A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation. |
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| interpreting the data and deriving a correct conclusion about the health status |
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| knowledge received as a whole, immediate recognition of patterns |
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Definition
| the determination of the cause of a patient's illness or suffering by the combined use of physical examination, patient interview, laboratory tests, review of the patient's medical records, knowledge of the cause of observed signs and symptoms, and differential elimination of similar possible causes. |
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| Nursing Diagnoses (actual, risk, wellness) |
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Definition
Nursing diagnoses are clinical judgments about a person's response to an actual or potential health state.
The list includes (1) actual diagnoses, existing problems that are amenable to independent nursing interventions; (2) risk diagnoses, potential problems that an individual does not currently have but is particularly vulnerable to developing; and (3) wellness diagnoses, which focus on strengths and reflect an individual's transition to a higher level of wellness. |
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| Nursing process (including steps of nursing process) |
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Definition
| Also based on the scientific method, the _______ _______ includes six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation |
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| what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination |
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Definition
| screening history, physical exam, counseling, immunizations, chemoprophylaxis |
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Term
| priority problems (first, second and third level) |
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Definition
Setting priorities when there is more than one diagnosis. In the hospitalized, acute care setting, the initial problems are usually related to the reason for admission. However, the acuity of illness often determines the order of priorities of the person's problems (Table 1-1).
For example, first-level priority problems are those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.
Second-level priority problems are those that are next in urgency—those requiring your prompt intervention to forestall further deterioration, for example, mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal laboratory values, risks of infection, or risk to safety or security. Ellen has abnormal physical signs that fit in the category of untreated medical problems. For example, Ellen's adventitious breath sounds are a cue to further assess respiratory status to determine the final diagnosis. Ellen's mildly elevated blood pressure needs monitoring also.
Third-level priority problems are those that are important to the patient's health but can be addressed after more urgent health problems are addressed. In Ellen's case, the data indicating diagnoses of knowledge deficit, altered family processes, and low self-esteem fit in this category. Interventions to treat these problems are more long term, and the response to treatment is expected to take more time. |
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Definition
| an objective finding as perceived by an examiner, such as a fever, a rash, the whisper heard over the chest in pleural effusion |
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| what the person says about himself or herself during history taking |
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| a subjective indication of a disease or a change in condition as perceived by the patient. |
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| checking the accuracy and reliability of data |
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| a move toward optimal functioning |
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