Critical Thinking in Health Assessment PDF

Critical thinking in Health Assessment  A clinical reasoning process 1. Analyze patient data 2. Develop hypotheses 3. Develop plan of care based upon hypotheses Nursing process  "S"ymptoms "It all started last week when...

Critical thinking in Health Assessment  A clinical reasoning process 1. Analyze patient data 2. Develop hypotheses 3. Develop plan of care based upon hypotheses Nursing process  "S"ymptoms "It all started last week when …." The patient's description of problem "My left arm feels stiff and sore" What the patient "s"ays "I tripped over the dog and …" The health history-chief complaint "And then I Subjective started getting the chills" "Bright lights Data seem to make it worse" OBJECTIVE DATA Signs Physical examination data Laboratory results Measurable findings Diagnostic studies  I think that there is a jellybean in my ear My legs feel like they are noodles! Erythema to distal left great toe Bilateral lung sounds with OBJECTIVE Blood pressure 188/90 crackles at the bases SUBJECTIVE The cramping gets worse after I eat Respiratory rate 28/labored I cannot seem to keep anything down! My pain is a 10/10!  Challenges of clinical data Assessing the quality of the data Subject to error Sifting through an extensive array of data Vague or confl icting details More than one reporter  Pull out separate clusters of observations Analyze one cluster at a time Ask a series of key How to work questions to guide in a specifi c direction through the Ask open-ended questions data Listen carefully and keep an open mind Confer with colleagues/clarify uncertainties  Reliability? Do repeat measurements of the Evaluating clinical same relatively stable fi ndings phenomenon give the same results? Validity? Does the given observation agree with “the true state of affairs”?  Assessment Now we Analyze! Three types of reasoning in problem solving: 1. Pattern recognition 2. Development of schemas 3. Application of relevant basic and clinical science  Identify Identify abnormal or positive findings Nursing analyses: Cluster Cluster the findings steps in clinical Interpret Interpret the findings reasoning Hypotheses Make hypotheses 84 year-old female presents with nausea, vomiting, and diarrhea x3 days. Lives alone – brought into hospital because daughter was concerned "she is very weak and unsteady." Ms. Lisbon states "my mouth is so dry" and "I feel light- headed just lying here." The daughter states her mom has felt unwell since attending a church event Friday. Mrs. Lisbon  Data gathered through assessment Oriented x 4 Groans when abdomen palpated Pale Drowsy Dry mouth "Hasn't slept well all week" Pulse 55 Temp 99 Sunken eyes/skin dry "Not really peeing" BP 90/58 "Thirsty" Weak pulses Last BM hours 1 ago/loose "Dizzy" "No energy" "Only drinks tea" "Maybe I ate some bad chicken?" "Could barely get out of bed" Recent weight loss (10lbs/2mos) "Glad to be around people-normally alone all day long" Normal daily intake: tea/toast - ½ sandwich (turkey) or soup - frozen dinner/soup Strength-weak x 4 "Lonely unless with church/daughter" "Never eats fruit/vegetables" Nursing process  Nursing diagnosis Based on real or potential health problems or human responses to health problems Based on assessment data and patient problem list Sets stage for remainder of care plan   Summarize the patient's problems Diagnose/Generating  Consider whether to the Problem List cluster data into single or multiple problems  Some disease processes will involve more than one body system  Consider the quality of the data https://www.nandadiagnoses.com  Nursing diagnosis vs. medical diagnosis Medical Nursing Diagnosis Diagnosis Pneumonia Impaired gas exchange Ineffective breathing pattern Knowledge defi cit Readiness for enhanced health maintenance Activity intolerance Risk for imbalanced nutrition; less than body requirements  Ms. Lisbon – Nursing diagnoses Nursing process  Devise the best course of action to address patient’s diagnoses Nurse and patient select goals for each diagnosis Set short-term goals (STG) and long-term goals (LTG) Be realistic Work with patient’s goals, economic means, competing responsibilities, and family structure and dynamics Planning  Must be agreeable to patient Patient-centered Develop/record plan for each problem Specify what steps are needed Share assessment with patient Ask the patient for his or her opinion Patient should always be an active participant of plan Adapt and change as problems change  The patient will....... Ms. Lisbon – Plan of action The patient will....... The patient will....... Nursing process  Evaluation Continuing process to determine if goals have been attained Based on patient’s condition Goals are realistic or appropriate Ongoing process Confi rms that nursing care is relevant Did our interventions work? Outcome met/not met …... Outcome met/not met ….. Outcome met/not met.....  Symptoms are also known as __________ data.  _________ indicates how closely a given observation agrees with the best possible measure of reality.  Objective data is information gathered from the physical assessment and the laboratory tests. TRUE or FALSE  __________ is devising the best course of action to address the patient's analyses.  _________ is a continuing process to determine if the goals have been attained. ONE thing I learned today……