Chapter 1: Evidence-Based Assessment

Subjective and objective data, together with the patient’s record and lab report, form a

Database

Subjective data

What the patient says or reports (can include patient’s family members)

Objective data

What you as a healthcare professional observe by inspecting, percussing, palpating, and auscultating during physical examination.

Follow-up Database

Database that evaluates effectiveness of treatment by checking whether symptoms of the disorder are alleviated or intensified. Status of identified problems are evaluated at regular, appropriate intervals.

Emergency Database

Rapidly established when the nurse requires a plan for immediate and effective treatment for the patient, often used concurrently with life-saving measures.

Complete Database

Describes current and past health state and forms baseline to measure all future changes. Used for caring for a patient with a (usually new) medical diagnosis. Includes a physical examination, reviewing the patient’s medical history, and learning patient’s attitude, coping skills, and support base.

Focused or Problem-centered Database

“Mini database” used when the nurse is interested in a specific short-term problem. The nurse should collect data based on one problem, one cue complex, and one body system.

Third-level priority problem

Problems important for the patient’s health but not urgent/life-threatening. Interventions to treat these problems are generally long-term.

E.g. impaired physical activity may cause obesity, but will not cause immediate health crisis

Second-level priority problems

Problems that require prompt, but not immediate, intervention to forestall further deterioration. Is not immediately life-threatening, but delay could cause harm/death.

First-level priority problems

Are those that are emergent, life threatening, and immediate, such as establishing an airway or supporting breathing.

Example of second-level problems

Change in mental status, acute pain, risk of infection, untreated medical problems, acute urinary elimination problem, abnormal lab values, or risks to safety or security

ABC prioritization

A - First, assess if airway is clear

B - Second, assess if breathing/respiration rate or O2 levels

C - Third, assess if blood is circulating properly.

Abductive reasoning

Initially use abductive when working with an incomplete data set

Deductive Reasoning

Used after abductive, as you apply physiology and pathophysiology

Inductive reasoning

Used after deductive as you use signs & symptoms

Novice Nurse

Has no experience with a specified patient population and uses rules to guide performance. May treat all data the same.

Competent nurses

Novice nurse begins to take actions in the context of patient goals or plans of care

Proficient Nurses

Understands the patient’s situation as a whole rather than as a list of tasks. Can see long-term goals for the patient and understand how today’s interventions will help the patient in the future.

Expert Nurses

Expert nurses vault over the steps and arrive at a clinical judgment in one leap. The expert has an intuitive grasp of a clinical situation and zeroes in on the accurate solution.

Interdisciplinary approach

Healthcare practitioners from a variety of specialties interact to improve outcomes for complex problems.

1850s

Historical evolution of the concept of “research” evidence began with Florence Nightengale

1970s

“Evidence-based medicine” term defined in the context of clinical research methods

1970-1980

Focus on “research utilization” which is now termed Evidence-based practice (EBP)

EBP

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

Clinical decision making is based upon

Best evidence from literature/research review + patient’s preference + clinician’s experience/expertise + physical examination

Social Determinants of Health (SDoH)

Are factors that influence a person’s health and well-being. They include the environment, access to health care, community, education, and economic stability. Recognize potential barriers to good health and work with the patient to determine solutions.

You have an outpatient who consistently misses appointments. Instead of assuming noncompliance or lack of desire to seek health care, what do you speak to the patient about?

Be cognizant of SDoH. Perhaps they lack reliable transportation and your clinic is in an area that is not serviced by public transportation. Can a social worker help set up transportation? Is there a clinic near public transportation that would be better for the patient?

Majority-minority nation

U.S. is a majority-minority nation, meaning that culturally appropriate care must be provided.

Epigenetics

Study of how environment and behaviors

impact gene expression