Chapter 1: Evidence-Based Assessment Flashcards

A set of vocabulary flashcards covering key definitions and clinical decision-making models from Chapter 1 Evidence-Based Assessment.

Assessment

The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community.

Database

The combination of subjective data, objective data, the patient's record, and laboratory studies that allows the nurse to make a clinical judgment or diagnosis about the patient's health state.

Diagnostic Reasoning

The process of analyzing health data and drawing conclusions to identify diagnoses.

Cue

A piece of information, such as a sign, symptom, or 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.

Hypothetico-Deductive Model

A diagnostic reasoning framework that involves attending to initially available cues, formulating diagnostic hypotheses, gathering relevant data, and evaluating each hypothesis with ongoing data collection.

Novice Practitioner

A practitioner starting out in an area of learning who uses rules to guide performance.

Competent Practitioner

A practitioner building on 2 to 3 years of clinical experience who sees actions in the context of patient goals or plans.

Proficient Practitioner

A practitioner who understands the patient situation as a whole rather than individual parts and applies long-term goals by adding to time and experience.

Expert Practitioner

A practitioner who has attained mastery of an area of learning and performs clinical judgment using intuitive analysis.

Nursing Process Model

A systematic clinical judgment process consisting of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation.

Evidence-Based Practice (EBP)

The integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences in clinical decision making.

Evidence-Based Clinical Decision Making

A clinical framework that relies on four factors: best evidence from research/literature, patient preferences and values, clinical expertise, and physical examination and assessment.

Complete Total Health Database

A database that includes a complete health history and full physical examination, describing current and past health state and forming a baseline to measure all future changes.

Episodic or Problem-Centered Database

A mini database collected for limited or short-term problems that concerns mainly one problem, one cue complex, or one body system.

Follow-Up Database

A database collected at regular intervals to evaluate the status of identified problems, note changes, evaluate progression, and identify coping strategies.

Emergency Database

A rapid collection of data often compiled concurrently with lifesaving measures when diagnosis must be rapid and comprehensive.

First-Level Priority Problems

Emergent, life-threatening, and immediate clinical issues requiring instant attention.

Second-Level Priority Problems

Clinical issues next in urgency that require prompt attention to avoid or prevent further deterioration.

Third-Level Priority Problems

Clinical issues that are important to the patient's health but can be addressed after more urgent problems are resolved.

Collaborative Problems

Physiological complications in which the approach to treatment involves multiple health care disciplines.

Holistic Model of Health

A model of care where mind, body, and spirit are interdependent and function as a whole within an open human environment.