Chapter 1 - Evidence-Based Assessment

Assessment

The collection of data about the individual's health state. (ex. clinical record review, interview, health history, physical exam, functional assessment, cultural/spiritual assessment, consultation, and literature review)

Subjective Data

What a patient says about themself during history taking. (ex. pain, emotions, anything stated that cannot be verified)

Objective Data

Observed during inspection, percussion, palpation, and auscultation during a physical examination. (ex. heart rate, bleeding, temperature, etc.)

Database

From subjective and objective data, plus the patient's record and laboratory studies.

Diagnostic Reasoning

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

Nursing Process

A five-step process that includes assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

Assessment Phase

Gather the data from the medical record and the patient, and complete an assessment.

Diagnosis Phase

Clinical findings are interpreted, and clinical judgement is used to determine a diagnosis.

Planning Phase

On the basis of the diagnosis, formulate goals and outcomes in collaboration with the patient.

Implementation Phase

Take action to implement the care plan and evaluate results.

Evaluation Phase

Assessing the effectiveness of nursing interventions, reassessment, or change of the original plan may be needed.

Critical Thinking Principles

• Proceed through sequential steps from novice to expert

• Incorporation of experience provides a foundation for the development of clinical practice

• Case studies and simulations are useful

• Utilize a multidimensional thinking approach to interpret data.

• Validate and confirm findings based on nonjudgmental interpretation of data.

• Cluster data information to support evidence as well as rule out inconsistent clinical findings in terms of differential diagnosis.

First-Level Priority Problems

Emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing.

Second-Level Priority Problems

Next in urgency, requiring prompt intervention to forestall further deterioration. (ex. mental status change, acute pain, acute urinary elimination issues, untreated medical problems, abnormal lab values, infection risk, or safety/security risk)

Third-Level Priority Problems

Important to the patient's health, but can be addressed after more urgent problems are addressed. Interventions to treat these problems are long-term, and the response to treatment is expected to take more time. These problems may require a collaborative effort betwen the patient and health care professionals.

Collaborative Problems

The approach to treatment involves multiple disciplines; interdisciplinary.

Evidence-Based Practice (EBP)

A multifaceted integration of research evidence, clinical expertise, clinical knowledge, and patient values/preferences that reflects holistic practice.

Complete (Total Health) Database

Includes a complete health history and full physical exam, and describes the current/past health state and forms a baseline against which all future changes can be measured.

Focused or Problem-Centered Database

For limited or short-term problems. Collect a "mini" database, smaller in scope. It concerns mainly one problem, one cue complex, or one body system.

Follow-Up Database

The status of any identified problems should be evaluated at proper intervals.

Emergency Database

An urgent, rapid collection of crucial information, often compiled concurrently with lifesaving measures. Diagnosis must be swift and sure.

Comprehensive Health Care

A thorough assessment is integral to providing comprehensive health care.

Holistic Health

Views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Everyone defines "healthy" differently.

Social Determinants of Health (SDoH)

Factors that influence a person's health and well-being. They include the environment, healthcare access, community, education, and economic stability. Some are modifiable; others are nonmodifiable.

Epigenetics

The study of how the environment and behaviors impact gene expression.