Nursing Evidence Based Assessment

Nursing Evidence Based Assessment

• Assessment is the starting point for all clinical reasoning models
• The nursing process is used for clinical judgment
• Critical thinking is needed for sound diagnostic reasoning and clinical judgments
• Prioritization of problems (first-level, second-level, third-level, and collaborative) is crucial
• The expanded concept of health is related to the process of data collection

Registered Baccalaureate Nurse Responsibilities

• Perform health histories and physical examinations before critical decisions
• Provide health promotion, counseling, and education
• Administer medications and other personalized interventions
• Coordinate care with various healthcare professionals

Nursing Process Overview

• A scientific method for providing the best patient care
• A problem-solving approach to clinical judgment
• Consists of five steps (Assessment, Diagnosis, Planning, Implementation, Evaluation)

Phases of the Nursing Process

• Assessment: Collecting subjective (what the patient says) and objective (observe) data
• Diagnosis: Analyzing subjective and objective data to identify and prioritize patient problems. Determine the concern by analyzing data
• Planning: Generating solutions, developing a plan, and prioritizing interventions; take action, meet the needs first
• Implementation: Prioritize interventions and implement the plan
• Evaluation: Assess if the outcomes have been met and if interventions were effective

Comprehensive Health Care

• Requires a thorough assessment
• Assessment data enables providers to develop a plan of care and provide appropriate quality care
• Includes holistic health (considering the patient as a whole)
• Emphasizes the role of genetics and environment
• Considers social determinants of health (factors that influence a person's well-being), such as economic stability, access to healthcare, community, and education

Patient Data Types

• Complete (Total Health) Database: Comprehensive history and examination, used as a baseline for future comparisons
• Follow-Up Database: Evaluates identified problems at regular intervals
• Focused/Problem-Oriented Assessment: Targeted to a specific, limited, or short-term problem
• Emergency Database: Rapid assessment for life-threatening situations (e.g., choking, cardiac arrest)

Subjective vs. Objective Data

• Subjective Data: Information from the patient (e.g., biographic data, reason for seeking care, history of present illness, past history, family history, review of systems, functional assessment)
• Objective Data: Observable information (e.g., physical characteristics, body functions, appearance, behavior, measurements, lab results)

Critical Thinking in Nursing

• Essential for sound clinical judgment
• Requires avoiding assumptions and remaining nonjudgmental
• Prioritization of problems:
  • First-level priority: Emergent, life-threatening problems (ABCs)
  • Second-level priority: Require immediate intervention (e.g., mental status change, acute pain)
  • Third-level priority: Important to client's health but can wait until more urgent problems are addressed (e.g., lack of knowledge, mobility issues, family coping, etc.)

This quiz covers essential aspects of the nursing process, emphasizing the importance of evidence-based assessment in clinical reasoning. It explores the roles and responsibilities of registered baccalaureate nurses and provides an overview of the phases involved, from assessment to evaluation. Test your knowledge on critical thinking and prioritization in patient care.