Topic 1
Evidence-Based Assessment
Objectives for the Week
Assessment is the initial step in the nursing process, crucial for planning client and family-centered nursing care.
As nurses, we assess clients, recognize cues, and cluster information to formulate a nursing diagnosis.
Types of Data Collection in Assessment
Subjective Data: Information shared by the client or caregiver.
Objective Data: Observable data collected by the nurse through physical examination techniques:
Inspection
Percussion
Palpation
Auscultation
Types of Databases in Nursing
The type of database used depends on the clinical setting and client situation.
Complete Database:
Collected when no prior information on the client exists, typically in a provider's office or clinic.
Includes a full health history (past and current health problems) and a comprehensive head-to-toe physical assessment.
Focused (or Problem-Centered) Assessment/Database:
Used for a limited or acute problem the client presents with.
Example: A client presenting with a fever and a sore throat.
Follow-Up Database:
Utilized in all healthcare settings.
Purpose: To assess if an identified problem has improved, to monitor chronic conditions for deterioration, and to detect any recent changes in health status.
Emergency Database:
A rapid collection of data during a life-threatening emergency.
Examples: An allergic reaction or a drug overdose.
A more thorough database is collected once the client's condition stabilizes.
Clinical Judgment and Diagnostic Reasoning
Nurses employ clinical judgment and diagnostic reasoning to develop nursing diagnoses after gathering assessment information.
Critical thinking principles are essential for nurses to analyze collected data and make optimal evidence-based decisions that directly impact bedside care.
Critical Thinking Principles
Critical thinking skills progress through sequential steps, evolving from novice to expert as experience is gained.
Utilize a multi-dimensional thinking approach to interpret data effectively.
Validate and confirm findings based on a non-judgmental interpretation of the collected data.
Cluster data and information to support evidence and to rule out inconsistent clinical findings when considering a differential diagnosis.
Priority Problem Levels
First-Level Priority:
Emergent, life-threatening, and requiring immediate attention.
Second-Level Priority:
Next in urgency, demanding attention to prevent further deterioration of the client's condition.
Third-Level Priority:
Important for the client's health but can be addressed after more urgent problems have been resolved.
Collaborative Problems:
Involve a multi-disciplinary approach to treatment, integrating various disciplines such as therapies (e.g., physical, occupational), nutrition, and dietary services.
Clinical Decision Making
Randomized Clinical Trials (RCTs):
Represent current and best clinical practices, based on rigorous research standards and focused on systematic reviews.
Evidence-based practice (EBP) has been a cornerstone since the 1970s.
RCTs are continuously conducted in many clinical settings, and nurses will encounter them during their clinical practice.
These trials establish the standard of care that significantly improves client outcomes.
Evidence-Based Practice (EBP):
Utilized in conjunction with provider experience to achieve better outcomes for clients in specific situations.
EBP is considered the "gold standard" in nursing.
This culture of EBP is evident at both undergraduate and graduate levels in nursing education.
High-Level Assessment Skills
Assessment skills necessitate hands-on expertise, refined to a high level through practice.
Nurses are often the first, and sometimes the only, healthcare professionals to see an individual in many communities.
In hospitals, nurses are continuously present at the bedside, acting as the "eyes and ears" of providers.
Emphasizing life cycle holism and cultural considerations must not diminish the intrinsic importance of core assessment skills.
The more clients a nurse assesses, the greater their expertise in clinical settings.
Assessment Through the Life Cycle
Assessments encompass growth and development, age-specific milestones, and immunizations.
These are examples of health promotion and disease prevention assessments conducted during a "Well Visit." Further details will be covered in Pediatrics (Peds) and Obstetrics (OB) courses.
Age-specific charts recommend periodic health examinations, offering a proactive approach to health assessment.
These charts provide a defined "Lifetime schedule of Health Care," listing services and their frequency for specific age groups.
Age-specific charts highlight major risk factors pertinent to each age group, informed by lifestyle, health needs, and prevalent problems.
It is crucial to integrate health promotion and disease prevention measures into every health visit, not just the annual physical examination.
Frequency of Assessments
The interval between assessments varies depending on the client's illness and wellness needs.
Ill individuals typically seek care due to pain or abnormal signs and symptoms.
Hospitalized clients require frequent, repeated head-to-toe and focused reassessments in response to ongoing treatments.
This necessitates gathering a complete, episodic, follow-up, or emergency database in a hospitalized client.
Routine Periodic Examinations (Preventative Health Care) Services:
Screening history for dietary intake, physical activity, tobacco, alcohol, drug use, and sexual practices.
Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health.
Immunizations.
Prophylaxis with a multivitamin containing folic acid for females capable of or planning a pregnancy.
Annual/Yearly Checkups for Well Persons:
Opinions regarding the necessity and frequency of annual checkups are evolving.
The term "annual checkup" can be vague, and it may sometimes offer an "implicit promise of health," potentially providing false security to the client.
The timing of formally accepted procedures is now variable; for instance, after several normal Pap tests, intervals may be extended.
A single, routine physical examination cannot be uniformly recommended for all persons because health priorities differ significantly among individuals, age groups, and risk categories.
Determining the frequency of provider visits for a client requires assessing individual risk factors.
HIPAA (Health Insurance Portability and Accountability Act of 1996)
HIPAA's official government website is the authoritative source for information.
Confidentiality Scope: HIPAA covers all written, verbal, and electronic communications concerning Protected Health Information (PHI).
Nurse's Obligation:
Never discuss or review client information at a clinical site unless it is directly part of your assigned duties.
You are legally and ethically obligated to understand and adhere to the privacy policies and HIPAA procedures of each clinical site.
Medical records, accounting information, client data, and conversations among healthcare professionals about clients are strictly confidential under this law.
You may not remove any client record from a clinical site without explicit written authorization.
Disclosure of client information during clinical assignments is restricted to the medical staff of the clinical site, including your clinical instructor.
When participating in learning experiences (classrooms, case presentations, assignments, research), you must attempt to exclude as much identifying client information as possible, as all such information is covered under HIPAA.
Essentially, any information that can be linked back to a client is protected under HIPAA.
Educational Disclosure Exception at Grand Canyon University (GCU):
Information covered under HIPAA can be disclosed for healthcare training and educational purposes at Grand Canyon University.
Otherwise, it remains confidential.
Reporting Violations:
Promptly report any violation of the clinical site's privacy policies, applicable law, or the confidentiality agreement by yourself or any GCU student or faculty member to the appropriate GCU clinical coordinator or program director.
Disciplinary Action: You will face disciplinary action if you fail to adhere to privacy policies, applicable law, or this agreement.
HIPAA "What If" Scenarios:
Question: If a spouse has not been appointed as a medical Power of Attorney (POA), can they receive client information?
Answer: No.
Question: Can client information be placed in the trash or recycle bin when you are working in healthcare?
Answer: No.
Question: Can you access your own medical record when you are working in healthcare?
Answer: No.
General Survey Part 3
Characteristics of a General Survey:
Begins the moment the nurse walks into the room.
It's a comprehensive study of the whole person, covering their general health state and any obvious physical characteristics.
Serves as an introduction to the physical examination that will follow.
Should provide an overall general impression of the person.
Utilizes objective parameters that apply to the whole person, not just a single body system.
Initial Questions for the Nurse:
"What questions will you ask yourself as you walk in the room?"
"What questions will you ask the client?"
"What does the client's environment look like (clinic, provider office, hospital room)?"
The Encounter (Immediate Impression):
Does the person stand promptly when called and walk easily?
Do they appear sick?
Are they rising slowly or with effort?
Are their shoulders slumped, eyes lacking luster, or downcast?
Can they converse without difficulty, read, watch television, or are they lying perfectly still?
Greeting and Initial Data Collection:
Introduce yourself and shake hands (if appropriate).
Observations during handshake: Does the person fully extend their arm, offer a firm handshake, make eye contact, or smile? Are their palms dry or wet and clammy?
Integration with Health History and Measurements:
Throughout the health history, measurements, and vital signs, make notes that contribute to the General Survey.
Assess if findings are expected or unexpected/abnormal.
Verify height, weight, and vital signs are within the normal range for the client's age.
Four Areas to Consider in a General Survey (Objective Data):
Physical Appearance
Body Structure
Mobility
Behavior
1. Physical Appearance:
Age: Does the person appear to be their stated chronological age?
Sexual Development: Is it appropriate for their gender and age?
Level of Consciousness: The person should be alert and oriented, attentive to questions, and respond appropriately.
Skin Color: Tone should be even; pigmentation varies based on genetic background. Skin should be intact with no obvious lesions.
Facial Features: Should be symmetrical with movement, and there should be no signs of acute distress.
2. Body Structure:
Stature: Height should appear within the normal range for their age and genetic heritage.
Nutrition: Weight should appear within the normal range for their height and build; body fat distribution should be even.
Symmetry: Body parts should look equal bilaterally and be in relative proportion to each other.
Posture: The person should stand comfortably erect as appropriate for their age.
Exceptions: An aging person may exhibit a stooped posture with kyphosis.
Position: The person should sit comfortably in a chair, on the bed, or examining table, with arms relaxed at their sides and head turned toward the examiner.
Body Build and Contour: Proportions should be correct, meaning: \text{armspan (fingertip to fingertip)} \approx \text{height} and \text{body length (crown of head to pubis)} \approx \text{length (pubis to sole of foot)}
Obvious Physical Deformities: Note any congenital or acquired defects.
3. Mobility:
Gait:
The base (distance between feet) should be approximately as wide as the shoulder width.
Foot placement should be accurate.
The walk should be smooth, even, and well-balanced.
Associated movements, such as a symmetrical arm swing, should be present.
Range of Motion (ROM):
Note full mobility for each joint.
Movement should be deliberate, accurate, smooth, and coordinated.
There should be no involuntary movements.
4. Behavior:
Facial Expression:
The person maintains eye contact (unless there is a cultural taboo).
Expressions should be appropriate to the situation (e.g., thoughtful, serious, smiling).
Note their expression both when the face is at rest and during conversation.
Mood and Affect: The person should be comfortable and cooperative with the examiner, interacting pleasantly.
Speech:
Articulation: The ability to form words should be clear and understandable.
The stream of talking should be fluent with an even pace.
They should be able to convey their ideas clearly.
Word choice should be appropriate to their culture and education level.
The person communicates easily in the prevailing language, either independently or with an interpreter.
Dress:
Should be appropriate to the climate, appear clean, fit the body, and align with the person's culture and age group.
Examples: Amish women typically wear 19th-century clothing; Indian women from India may wear saris. Culturally determined dress should not be mislabeled as "bizarre" by Western standards or adult expectations.
Personal Hygiene: The person should appear clean and well-groomed for their age, occupation, and socioeconomic group.