Nursing Evidence Based Assessment Fall23 PDF

NURSING EVIDENCE BASED ASSESSMENT Objectives 1. Discuss the role of assessment as the starting point of all models of clinical reasoning. 2. Discuss the use of the nursing process in clinical judgment. 3. Describe the use of critical thinking in sound diagnostic reasoning and clinical judgmen...

NURSING EVIDENCE BASED ASSESSMENT Objectives 1. Discuss the role of assessment as the starting point of all models of clinical reasoning. 2. Discuss the use of the nursing process in clinical judgment. 3. Describe the use of critical thinking in sound diagnostic reasoning and clinical judgment. 4. Differentiate first-level, second-level, third-level priority, and collaborative problems. 5. Discuss the expanded concept of health and relate it to the process of data collection. Nurses are: oWhat types of nurses are there? oWhat does the Registered baccalaureate nurse do? ◦ Perform health histories and physical exams before making critical decisions ◦ Provide health promotion, counseling and education ◦ Administer medications and other personalized interventions ◦ Coordinate care, in collaboration with a wide array of health care professionals Nursing Process ◦What is it? ◦Problem solving approach to clinical judgment Phases of Nursing Process Assessment: Collecting _______________ and ______________ data (recognize cues) Diagnosis: Analyzing subjective and objective data to make and ___________________________________ (analyze cues) Planning: Generating _________________, developing a plan, and determining which ______________ need to be met first (prioritize hypotheses) Implementation: __________________, ______________ and _________________ planned interventions Evaluation: Assessing whether outcomes have been met and revising the plan if interventions not effective Comprehensive Health Care ◦ Requires a ____________________________________________! ◦ Assessment data provide important information that allows a provider to ____________ an appropriate _________________________________ and provide ___________, ____________ care. ◦ Holistic health ◦ Role of genetics and environment in health ◦ Social determinants of health (SDOH) Patient Data 4 types: ◦ Complete (Total Health) Database: includes a complete health history and a full physical examination, forms a baseline against which all future changes are compared. ◦ Follow-Up Database: evaluates status of any identified problems at regular and appropriate intervals. ◦ Focused/problem-oriented assessment: for a limited or short-term problem, collect a “mini” database that is targeted to a specific problem. ◦ Emergency Database: Very rapid assessment performed in life- threatening situations (choking, cardiac arrest, drowning). Subjective vs Objective Data Subjective Objective ◦ Biographic data ◦ Physical characteristics ◦ Reason for seeking care ◦ Body functions ◦ History of present illness ◦ Appearance ◦ Past history ◦ Behavior ◦ Family history ◦ Measurements ◦ Review of systems ◦ Results of laboratory testing ◦ Functional assessment Critical Thinking ◦ Required for sound clinical judgment ◦ Remain nonjudgmental ◦ Avoid making assumptions ◦ Allows you to prioritize ◦ First-level priority ________________, life threatening, and ______________________ (____) ◦ Second-level priority require prompt intervention to ______________________________________ (mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, risk to safety) ◦ Third-level priority important to client’s health but can be addressed after more urgent health problems are addressed (lack of knowledge, __________________________, _________________________)