Chapter 1: Evidence Based Assessment

Subjective Data

What the patient says during history taking

Objective data

what you have Observed about the patient during physical examination

Subjective data + objective data + patients record + laboratory studies =

The database

Information from database helps the nurse how?

Make clinical judgement or diagnoses about the patient’s health state

What is key?

Organization of assessment based on complete factually based data.

Diagnostic reasoning

Process of analyzing health data and drawing conclusions to identify diagnoses

What is a cue?

Piece of important information. A sign or symptom, or piece of laboratory or imaging.

Cluster

Grouping together data that appears to be causal or associated. Expert nurses are able to rapidly collect data and identify clusters.

Diagnostic reasoning is a combination of what?

deductive, inductive, and addictive reasoning

What is deductive reasoning?

You will draw on general principles from physiology and pathology.

What is inductive reasoning?

You will use signs and symptoms as a guide.

What is abductive reasoning?

Is thinking to determine the best explanation with the information at hand.

5 Steps of the nursing process

Assessment, Diagnosis, Planning, Implementation, & Evaluation

Assessment

Recognize cues

Diagnosis

Analyze cues

Planning

Prioritizing hypothesis, generate solutions

Implementation

Take action

Evaluation

Evaluate outcomes

Levels of nursing

Novice, competency, proficient, & expert

Novice

Starting out in an area of learning. Used rules to guide performance

Competency

Building on 2-3 years of clinical experience. See actions in the context of patients goals or plans.

Proficient

Adding to time and experience, understands the patients situation as a whole rather than individual parts —- Apply long term goals.

Expert

Attained mastery of an area of learning. Performs clinical judgement using intuitive analysis.

First-level priority

Emergent, life threatening, and immediate. Ex. airway or supporting breathing

Second-level priority

Next in urgency, requiring attention to avoid further deterioration. Ex. mental status change, acute pain, risk of infections, risk to safety or security

Third-level priority

Important to patient’s health but can be addressed after more urgent problems are addressed. Long term.

Interdisciplinary approach

Treat complex medical problems

Evidence-based practice (EBP)

• Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences.

• Looking for gaps in literature

• evidence from literature + patients preference + clinician’s experience + physical exam

Complete total health database

Describes current and past health state and forms baseline to measure all future changes.

Episodic or problem-centered database.

Collect “mini” database, smaller scope and more focused than complete database.

Follow-up database

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

Emergency database

Rapid collection of data often compiled concurrently with lifesaving measures

Holistic model

Interdependent functioning of mind, body, and spirit to maintain optimal health

Social determinants of health

Factors that influence well-being: environment, access to health care, community, education & economic stability. Impact of potential barriers.

Epigenetics

Study of how environment and behaviors impact gene expression