Nursing Assessment Basics

• Assessment is the first step in the nursing process
• Assessment serves as the foundation for all clinical reasoning and decision-making
• Assessment involves the systematic collection of subjective and objective data to determine a patient's health status, formulate nursing diagnoses, and guide care

Key Goals of Assessment

• Gather complete and accurate health data.
• Identify normal and abnormal findings.
• Establish a database for future comparison.
• Use evidence-based practice (EBP) to enhance patient outcomes.
• Identify priorities in patient care and formulate clinical judgments.

Components of Health Assessment

• Subjective data: Information reported by the patient like symptoms and health history
• Objective data: Observations and measurements obtained during the physical exam like vital signs and lab results

Four Types of Patient Databases

• Complete database includes full health history & physical exam; used in primary care & first visits like an annual check-up
• Focused database targets a specific focused issue; used in all settings like a patient with a rash in dermatology clinic
• Follow-up database evaluates existing problems over time like a hypertension patient returning for BP check
• Emergency database provides urgent, rapid assessment for life-threatening situations like a trauma patient in the ER

Steps in Diagnostic Reasoning

• Recognize cues by identifying abnormal findings
• Cluster related data to group symptoms/signs to recognize patterns
• Generate hypotheses to consider possible causes for findings
• Test hypotheses by collecting additional information to confirm/refute a diagnosis
• Establish a diagnosis by making clinical decisions based on evidence

Critical Thinking in Assessment

• Novice nurses rely on rules & guidelines
• Experienced nurses use intuition & pattern recognition
• Experienced nurses can identify relevant vs irrelevant data faster

The Nursing Process (5 Steps)

• Assessment involves collecting subjective & objective data
• Diagnosis involves identifying patient problems based on assessment
• Planning involves setting measurable goals & expected outcomes
• Implementation involves carrying out interventions to achieve goals
• Evaluation involves assessing the effectiveness of interventions & revise if needed
• The nursing process is cyclic, and if interventions fail, reassessment is needed

Priority Setting in Clinical Judgment

• First-level priority: Life-threatening conditions requiring immediate action, such as airway obstruction or cardiac arrest
• Second-level priority: Requires quick intervention to prevent worsening, such as acute pain or abnormal lab values
• Third-level priority: Important but can be addressed later, such as knowledge deficits or mobility issues
• Always address life-threatening problems first (ABCs: Airway, Breathing, Circulation).

Evidence-Based Practice (EBP) in Nursing

• EBP is the integration of best research evidence, clinical expertise, patient values, and physical assessment findings to improve health outcomes

Five Steps of EBP

• Ask by formulating a clinical question
• Acquire by gathering research evidence
• Appraise by critically evaluating evidence quality
• Apply by implementing findings into practice
• Assess by evaluating the effectiveness of intervention

EBP Example

• Using corticosteroids in preterm labor to reduce neonatal mortality, which was previously ignored despite strong research evidence

Barriers to EBP

• Lack of time & research skills
• Limited access to resources
• Resistance to change in clinical settings

Overcoming Barriers to EBP

• Encourage EBP training
• Provide research access
• Foster a culture of critical thinking in nursing practice

Case Study Review

• A 23-year-old pediatric nurse visits the clinic for a routine physical exam with a comprehensive health history and head-to-toe assessment
• The patient has type 1 diabetes since age 12 that is managed with an insulin pump
• The patients past medical history includes: Hypoglycemic seizures, tympanostomy tubes as a child
• The patients lifestyle & health promotion includes: Regular exercise, monthly breast self-exam, sunscreen use
• The patients social situation includes: Close family relationships, no significant other
• The patients BP is 108/72 mmHg, BMI is 29 (overweight)
• The patients concerns revolves around: Blood sugar fluctuations during life transitions

Key Takeaways

• Assessment is the foundation of nursing practice
• Clinical judgment relies on data collection, critical thinking, and prioritization
• Evidence-based practice improves patient care and outcomes
• The nursing process is a dynamic cycle of assessment, diagnosis, planning, intervention, and evaluation