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What patient says about himself or herself during history taking

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Subjective data

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Observed when inspecting, percussing, palpating, and auscultating patient during physical examination

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Objective data

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Formed from these elements, plus patient's record and laboratory studies

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Database

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Attend to initially available cues Formulate diagnostic hypotheses Gather data relative to hypotheses Evaluate each hypothesis with new data collected to arrive at final diagnosis

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Hypodeductive model that contains four major components:

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Assessment Diagnosis Outcome identification Planning Implementation Evaluation

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Steps of the Nursing Process

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Collection of data from multiple sources

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Nursing Process: Assessment

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Review of clinical record Interview Health history Physical examination Functional assessment Cultural and spiritual assessment Consultation Review of the literature

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Where are some of the data collected from during the assessment?

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Interpretation of data by identifying clusters of cues so as to make inferences

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Nursing Process: Diagnosis

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clusters of cues with definitions and defining characteristics

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When making a nursing diagnosis what do you compare?

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Validation of inferences based on findings

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When making a nursing diagnosis what validates inferences?

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Identifying related factors

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In the nursing process of diagnosis what happens after validation of inferences?

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To document the diagnosis

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In the nursing process of diagnosis what is the last step?

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Identify expected outcomes related to patient individualization

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Nursing Process: Outcome Identification

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realistic and measurable

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In the nursing process outcome identification you should ensure that the outcomes are:

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short-term and long-term goal measurement criteria

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In the nursing process outcome identification what should you specifiy?

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Establish priorities based on meeting identified patient care goals

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Nursing Process: Planning

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outcomes and set time frames for meeting proposed outcomes

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In the nursing process planning, what should be developed early?

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relevant interventions and utilization of interdisciplinary health care team members in the care planning process

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In the nursing process planning, what should be identified?

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the plan of care

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In the nursing process planning, what should be documented?

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Determine patient readiness and involve patient(s) in health care process

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Nursing Process: Implementation

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interdisciplinary health care team members to facilitate collaborative efforts

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In the nursing process implementation who should you review planned interventions with and why?

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to utilize principles of delegation, being mindful of supervision and evaluation

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In the nursing process implementation what is important in regards to delegation?

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the person and significant others

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In the nursing process implementation who should you counsel?

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continuing care

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In the nursing process implementation what should you give a referral for?

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document care provided

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What is the last step in the implementation?

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Refer to established outcomes

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What is the first step in the Nursing Process: Evaluation

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the individual's condition and compare it to actual outcomes with expected outcomes

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In the Nursing process evaluation what should be evaluated?

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summarize the results of evaluation and identify reasons for failure to achieve expected outcomes

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In the Nursing process evaluation what is done with the results?

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take corrective action to modify plan of care and document evaluation in plan of care

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In the Nursing process evaluation what should be done after identifying reasons for failure

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Proceed through sequential steps from novice to expert

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Critical Thinking Principles

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based on non-judgmental interpretation of data

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How should you validate and confirm findings

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By Incorporating experiences which provide a foundation for development of clinical practices

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In the critical thinking process how does one move to novice to expert

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By using an organized, systematic assessment format

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In the critical thinking process how does one utilize a multidimensional thinking approach to interpret data

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By checking and corroborating the accuracy and reliability of data

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In the critical thinking process how does one validate and confirm findings based on nonjudgmental interpretation of data

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By clustering data information and distinguishing relevant signs and symptoms

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In the critical thinking process how does one support or rule out clinical findings

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First-level priority Second-level priority Third-level priority Collaborative problems

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Priority Problems Level

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Emergent, life threatening, and immediate

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What is the first-level priority

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Next in urgency, requiring attention so as to avoid further deterioration

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What is the second-level priority

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Important to patient's health but can be addressed after more urgent problems are addressed

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What is the third-level priority

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When approach to treatment involves multiple disciplines

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What is collaborative problems

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Identify patient outcomes and delineate measurable goals

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Problems and Outcomes

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continuously

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how often should you evaluate the plan of care

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evaluation methods that will allow for validation of results or adjustments to care planning

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what should be included when identifying problems and outcomes

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Qualify short-term and long-term goals that are realistic and patient centered

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What is most important when identifying patient outcomes

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Incorporation of evaluation and planning methods

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What is a critical element in the delivery of care

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By analyzing and implementing changes as needed in order to maintain pathway toward goal achievement

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How do you continuously evaluate the plan of care

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Evaluate and update plan, Record revised plan and keep it up-to-date

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Comprehensive Plan of Care

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because it is a legal document and may be needed for evaluation, insurance reimbursement, and research

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why is it important to have accurate recording of the care plan

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the multidisciplinary team

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who should you communicate the revised plans to

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Current and best clinical practice based on research standards focused on systematic reviews of randomized clinical trials (RCTs)

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Evidence-Based Assessment

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Utilizing evidence-based practice (EBP) in conjunction with provider experience

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What will lead to better health outcomes for patients

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Fostering a "culture of EBP" at both the undergraduate and graduate levels

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How will health educators make EBP the "gold standard" of practice

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Complete total health Episodic or problem-centered Follow-up Emergency

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Four Types of Data

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Includes complete health history and full physical examination, Describes current and past health state and forms baseline to measure all future changes Yields first diagnoses

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What is included in the complete total health database

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limited or short-term problems, Collect "mini" database, smaller scope and more focused than complete database

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What is included in the Episodic or Problem focused database

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Status of all identified problems should be evaluated at regular and appropriate intervals

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What is included in the follow up database

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coping strategies being used

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what else should be identified in the follow up database

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changes that have occurred, whether problem is getting better or worse

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what should the interviewer take note of with the follow up database

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Rapid collection of data, often compiled concurrently with lifesaving measures, Diagnosis must be rapid and comprehensive in nature

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What is included in the emergency database

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Mind, body and spirit are interdependent and function as a whole, Multifaceted basis of disease

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Holistic Model of Health

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Interval of assessment varies with illness and wellness needs, Includes Routine Periodic Examination,

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Frequency of Assessment

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because of pain or abnormal signs and symptoms

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Why do ill people usually seek care?

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This prompts an assessment: gathering a complete, episodic, or emergency database

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What is prompted when ill people seek care?

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dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices

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When screening history what is included?

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injury prevention, substance use, sexual behavior, diet and exercise, and dental health

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Counseling includes?

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Chemoprophylaxis for multivitamin with folic acid for females capable of or planning pregnancy

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Routine periodic examination might also include the following services for preventive health care:

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