[NSG 261] - Final Exam Guide - Comprehensive Notes for the exam (39 pages long!)
Document Summary
Assessment: a collection of data about the individuals health: purpose: make a clinical judgment or diagnosis, starting point of every approach to clinical reasoning, all health care decisions are based off of this data. Data sources: history (subjective-what they tell you, physical exam (objective) Clinical reasoning models include: diagnostic reasoning, critical thinking, nursing processes, assessment. Collect data: review of clinical record, health history, physical exam, functional assessment, risk assessment, review of the literature. Evidence based practice and document data: diagnosis. Interpret data by identifying clusters of cues and making inferences. Compare clusters of cues with definitions and defining characteristics. Establish priorities: airway problems, breathing problems, cardiac/circulation problems, vital sign concerns. Evaluate individuals condition and compare actual outcomes with expected outcomes. Identify reasons for failure to achieve expected outcomes. Take corrective action to modify plan of care. Evidence based decisions are based on : evidence from research and evidence based theories, physical exam and assessment, patient preferences and values, clinical expertise.
