Nursing Evidence-Based Assessment

Nursing Evidence Based Assessment

• Objectives:
  • Assessment is the starting point for all clinical reasoning models.
  • The nursing process is used in clinical judgment.
  • Critical thinking is used in diagnostic reasoning and clinical judgment.
  • First-level, second-level, third-level, and collaborative problems are differentiated.
  • The expanded concept of health is discussed and related to data collection.

Nurses

• Registered Baccalaureate Nurse Responsibilities:
  • Perform health histories and physical exams before decisions.
  • Provide health promotion, counseling, and education.
  • Administer medications and other personalized interventions.
  • Coordinate care with other health care professionals.

Nursing Process

• Definition:
  • A scientific method for providing the best patient care.
  • A problem-solving approach for clinical judgment.
  • Uses the ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) method.

Phases of Nursing Process

• Assessment:

  • Collecting subjective (patient's report or verbal statements) and objective (measurable) data.
  • Analyzing data to form a clinical judgment.

• Diagnosis:

  • Prioritizing and identifying client problems.

• Planning:

  • Generating possible solutions.
  • Determining the order interventions will be applied (prioritizing).

• Implementation:

  • Implementing the chosen plan of action.

• Evaluation:

  • Assessing if interventions were successful, and modifying the plan as needed.

Comprehensive Health Care

• Comprehensive Assessment: Required for thorough care.
• Assessment Data Value: Data provide necessary information to healthcare providers; essential for quality care.
• Holistic Health: The idea that a patient should be viewed in the context of their entire being.
• Social Determinants of Health (SDOH):
  • Environmental factors (economy, community resources, education)
  • Factors that influence a person's wellbeing.

Patient Data

• Complete Database: A full patient history and physical exam form a baseline to track changes.
• Follow-Up Database: Checks the status of identified problems in appropriate intervals.
• Focused/Problem-Oriented Assessment: Collects data specific to a limited or short-term problem.
• Emergency Database: A very rapid assessment performed in life-threatening situations.

Subjective vs. Objective Data

• Subjective: Data are the patient's self-description, reason for concern, past history etc.
• Objective: Data (observed characteristics, body functions, behaviors, lab results or measurement).

Critical Thinking

• Importance: Crucial for sound clinical judgment.
• Assumptions: Avoiding making unfounded assumptions.
• Prioritization:
  • First-Level Priority: Life-threatening situations (ABCs - Airway, Breathing, Circulation).
  • Second-Level Priority: Problems requiring quick intervention (e.g., altered mental status, acute pain).
  • Third-Level Priority: Health needs that can be addressed after more urgent concerns.

This quiz covers the essential concepts of evidence-based nursing assessment. It emphasizes the importance of the nursing process and critical thinking in clinical judgment. Topics include differentiating nursing problems and the expanded concept of health related to data collection.