Evidenced-Based Assessment
Evidenced-Based Assessment (EBA) Notes
I. Foundations of Assessment
A. Assessment: Point of Entry in an Ongoing Process
Definition: Assessment is the initial and most critical stage in the continuous process of patient care, serving as the fundamental basis upon which all subsequent clinical actions, such as diagnosis, planning, implementation, and evaluation, are built. It involves the systematic collection of comprehensive health data.
Database Components: A comprehensive database is meticulously formed by integrating several crucial types of information, ensuring a holistic view of the patient's health status:
Subjective Data: This includes all information reported directly by the patient or significant others, encompassing their perceptions, feelings, concerns, and symptoms (e.g., "I feel dizzy," "The pain is a sharp 7/10"). This data is crucial for understanding the patient's unique experience of illness and health.
Objective Data: This refers to measurable and observable information obtained through physical examination, observation, inspection, palpation, percussion, and auscultation. Examples include vital signs (e.g., blood pressure 120/80 ext{ mmHg}, heart rate 72 ext{ beats/min}), physical examination findings (e.g., skin turgor, lung sounds), and general appearance. This data provides concrete, verifiable facts.
Patient's Record: This comprises a patient's historical health information, including past medical history, previous diagnoses, treatments, medications, allergies, family history, and lifestyle factors. Reviewing the patient's record provides context and identifies risks or trends over time.
Laboratory Studies: These are results from various diagnostic tests, such as blood work (e.g., complete blood count, electrolyte levels), urinalysis, imaging studies (e.g., X-rays, MRI, CT scans), and other specialized tests. These studies offer critical insights into physiological functions and pathology.
Purpose: The meticulous collection and synthesis of this diverse data allow the nurse to formulate a precise clinical judgment or diagnosis regarding the patient's current health state. This judgment guides the development of individualized care plans.
Key Principle: The organization and interpretation of assessment data must be rigorously based on complete, accurate, and factually sound information. This commitment to data integrity is essential to ensure reliable clinical decisions, prevent errors, and promote optimal patient outcomes.
B. Diagnostic Reasoning
Definition: Diagnostic reasoning is an intricate, systematic cognitive process employed by clinicians that involves the thorough analysis and interpretation of all collected health data. The ultimate goal is to draw accurate conclusions and identify appropriate nursing or medical diagnoses that reflect the patient's health problems or conditions. It's a critical thinking skill that improves with experience.
Process Steps:
Cluster Correlated Data: This involves grouping together related pieces of information (cues) obtained during the assessment. Identifying patterns, relationships, and inconsistencies among these findings helps to synthesize complex data into meaningful categories. For instance, if a patient reports shortness of breath, a cough, and has crackles on auscultation, these cues might be clustered together to suggest a respiratory issue.
Cue: A cue is a piece of information, a sign, or a symptom obtained from the patient. It is an objective or subjective assessment finding that is considered "abnormal" or "significant" and prompts further investigation or suggests a potential health problem. Cues serve as building blocks for data clustering and diagnostic hypothesis generation. For example, a fever of 102^{\circ}\text{F} is a cue.