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Study Guide

NUR332 Study Guide - Spring 2019, Comprehensive Final Exam Notes - Palpation, Test Cricket, Health Promotion


Department
Nursing
Course Code
NUR332
Professor
Sullivan
Study Guide
Final

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NUR332

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Chapter 1: Evidence-Based Assessment
o Assessment: Point of entry in an ongoing process
o Subjective data: what patient says about himself or herself during
history taking
o Objective data: observed when inspecting, percussing, palpating, and
auscultating patient during physical examination
o Database: formed from subjective and objective data, plus patient’s
record and laboratory studies
o Diagnostic reasoning
o Hypodeductive model that contains four major components:
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
o Cue: a piece of information, sign, symptom, or piece of laboratory data
o Steps of the Nursing Process
o Assessment
o Diagnosis
o Outcome identification
o Planning
o Implementation
o Evaluation
o Nursing Process: Assessment
o Collection of data from multiple sources
Review of clinical record
Interview
Health history
Physical examination
Functional assessment
Cultural and spiritual assessment
Consultation
Review of the literature
o Nursing Process: Diagnosis
o Interpretation of data by identifying clusters of cues so as to make
inferences
o Compare clusters of cues with definitions and defining characteristics
o Validation of inferences based on findings
o Identify related factors
o Document the diagnosis
o Nursing Process: Outcome Identification
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o Identify expected outcomes related to patient individualization
o Ensure outcomes are realistic and measurable
o Specify short-term and long-term goal measurement criteria
o Nursing Process: Planning
o Establish priorities based on meeting identified patient care goals
o Develop outcomes and set time frames for meeting proposed outcomes
o Identify relevant interventions and utilize interdisciplinary health care
team members in the care planning process for the patient
o Document plan of care
o Nursing Process: Implementation
o Determine patient readiness and involve patients in health care process
o Review planned interventions with interdisciplinary health care team
members to facilitate collaborative effort
o Utilize principles of delegation, being mindful of supervision and
evaluation
o Counsel person and significant others
o Refer for continuing care
o Document care provided
o Nursing Process: Evaluation
o Refer to established outcomes
o Evaluate individual’s condition and compare actual outcomes with
expected outcomes
o Summarize results of evaluation
o Identify reasons for failure to achieve expected outcomes
o Take corrective action to modify plan of care
o Document evaluation in plan of care
o Critical Thinking Principles
o Proceed through sequential steps from novice to expert
Incorporation of experience provides foundation for development
of clinical practice
o Utilize a multidimensional thinking approach to interpret data
Use an organized, systematic assessment format
o Validate and confirm findings based on nonjudgmental interpretation
of data
Check and corroborate accuracy and reliability of data
o Cluster data information to support evidence as well as rule out
inconsistent clinical findings in terms of differential diagnosis
Distinguish relevant signs and symptoms
o Priority Problems Level
o First-level priority
Emergent, life threatening, and immediate
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