Recording-2025-01-30T16:31:19.028Z

Evidence Based Assessment

• Assessment: Critical point of entry in the ongoing process of healthcare. It involves the collection of data regarding an individual's health state, which includes:

  • Subjective Data: Information reported by the patient during history taking.

  • Objective Data: Observable information gathered through physical examination methods including inspecting, percussing, palpating, and auscultating.

• Together, subjective and objective data form a comprehensive database from which clinical judgments can be made regarding the patient's health status and responses.

Clinical Judgments and Diagnostic Reasoning

• Clinical Judgment: Process of interpreting and integrating accumulated assessment data to form a diagnosis.

• Diagnostic Reasoning: Involves analyzing health data to make clinical decisions.

  • Utilizes a combination of:

    • Deductive reasoning: Drawing from general principles in physiology/pathology.

    • Inductive reasoning: Using specific signs and symptoms to inform assessments.

    • Abductive reasoning: Developing initial hypotheses when data is incomplete.

• Abductive Reasoning: Key in formulating hypotheses based on incomplete data, which establishes a starting point for further inquiry.

• Need to identify gaps in the information collected is emphasized as a critical thinking skill.

The Nursing Process

• The nursing process includes five stages:

  1. Assessment: Data collection from historical records and patients.

  2. Diagnosis: Interpretation of clinical findings to formulate diagnosis.

  3. Planning: Collaborating with patients to set goals and outcomes based on diagnosis.

  4. Implementation: Executing the care plan.

  5. Evaluation: Assessing outcomes and making necessary adjustments.

• Clinical Judgment Model:

  • Structured to enhance clinical judgment among practitioners.

  • Progresses from novice to expert level through experience, with experts often using intuitive assessments.

Prioritization of Problems

• Priority Problems:

  • 1st Level: Life-threatening issues requiring immediate attention (e.g., airway support).

  • 2nd Level: Urgent issues needing prompt intervention to prevent deterioration (e.g., mental status changes).

  • 3rd Level: Important but non-life-threatening concerns (e.g., long-term goals requiring collaborative efforts).

• Involvement of patients in care planning increases their commitment to the process, improving outcomes.

Evidence Based Practice (EBP)

• Origins: Traces back to Florence Nightingale's work during the Crimean War.

• Characteristics: Integration of:

  • Best evidence from research literature.

  • Clinical expertise.

  • Patient's values and preferences.

  • Results from physical assessment.

• EBP Steps:

  1. Ask a Clinical Question.

  2. Gather Research Evidence via literature search.

  3. Review & Synthesize Findings.

  4. Apply Evidence & Evaluate Results.

Types of Patient Data

• Complete Total Health Database:

  • Health history and physical examination, forming a baseline for future comparisons.

  • Gathered usually in primary care settings.

  • Includes health strengths, coping mechanisms, and lifestyle factors for both well individuals and those with health problems.

• FOCUS or Problem-Centered Database:

  • Limited scope targeting specific problems or systems, used in various healthcare settings.

• Follow-Up Database:

  • Assessing the status of identified problems at regular intervals.

• Emergency Database:

  • Rapid collection of essential information while life-saving measures are performed.

  • Gathered from responsive patients or caregivers if the patient is unresponsive.

Holistic Health and Comprehensive Care

• Holistic View: Considers the interplay between mind, body, and spirit and recognizes the importance of patient involvement.

• Social Determinants of Health (SDOH): Factors impacting health and well-being including environment, healthcare access, community resources, education, and economic stability.

• Cultural Competency: Recognizes the necessity of providing care that is sensitive to cultural differences.

• Epigenetics: Studies how environment and behaviors influence gene expression, highlighting the importance of genetics in the context of health and wellness.