Chapter 1

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Evidence-Based AssessmentEvidence-Based Assessment

Chapter 1Chapter 1


Chapter 1: Evidence-Based AssessmentChapter 1: Evidence-Based Assessment

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Assessment: Assessment: Point of Entry in an Ongoing ProcessPoint of Entry in an Ongoing Process Subjective dataSubjective data

What patient says about himself or herself during What patient says about himself or herself during history takinghistory taking

Objective dataObjective data Observed when inspecting, percussing, palpating, Observed when inspecting, percussing, palpating,

and auscultating patient during physical and auscultating patient during physical examinationexamination

Data baseData base Formed from these elements, plus patient’s record Formed from these elements, plus patient’s record

and laboratory studiesand laboratory studies



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Clinical Reasoning ModelsClinical Reasoning Models

Diagnostic reasoningDiagnostic reasoning Nursing processNursing process Critical thinkingCritical thinking



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Diagnostic ReasoningDiagnostic Reasoning

Attend to initially available cuesAttend to initially available cues CueCue: piece of information, sign, symptom, or piece : piece of information, sign, symptom, or piece

of laboratory dataof laboratory data Formulate diagnostic hypothesesFormulate diagnostic hypotheses

HypothesisHypothesis: tentative explanation for cues used as : tentative explanation for cues used as a basis for further investigationa basis for further investigation

Gather data relative to tentative hypothesesGather data relative to tentative hypotheses Evaluate each hypothesis with new data Evaluate each hypothesis with new data

collected to arrive at final diagnosiscollected to arrive at final diagnosis



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Nursing ProcessNursing Process

AssessmentAssessment DiagnosisDiagnosis Outcome identificationOutcome identification PlanningPlanning ImplementationImplementation EvaluationEvaluation



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Nursing Process: AssessmentNursing Process: Assessment

Collect dataCollect data Review of clinical recordReview of clinical record InterviewInterview Health historyHealth history Physical examinationPhysical examination Functional assessmentFunctional assessment Cultural and spiritual assessmentCultural and spiritual assessment ConsultationConsultation Review of the literatureReview of the literature



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Nursing Process: DiagnosisNursing Process: Diagnosis

Interpret dataInterpret data Identify clusters of cuesIdentify clusters of cues Make inferencesMake inferences

Validate inferencesValidate inferences Compare clusters of cues with definitions and Compare clusters of cues with definitions and

defining characteristicsdefining characteristics Identify related factorsIdentify related factors Document the diagnosisDocument the diagnosis



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Nursing Process:Nursing Process:Outcome IdentificationOutcome Identification

Identify expected outcomesIdentify expected outcomes Individualize to patientIndividualize to patient Ensure outcomes are realistic and Ensure outcomes are realistic and

measurablemeasurable Include a time frameInclude a time frame



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Nursing Process: PlanningNursing Process: Planning

Establish prioritiesEstablish priorities Develop outcomesDevelop outcomes Set time frames for outcomesSet time frames for outcomes Identify interventionsIdentify interventions Document plan of careDocument plan of care



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Nursing Process: ImplementationNursing Process: Implementation

Determine patient readinessDetermine patient readiness Review planned interventionsReview planned interventions Collaborate with other team membersCollaborate with other team members Supervise by delegating appropriate Supervise by delegating appropriate

responsibilitiesresponsibilities Counsel person and significant othersCounsel person and significant others Involve person in health careInvolve person in health care Refer for continuing careRefer for continuing care Document care providedDocument care provided



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Nursing Process: EvaluationNursing Process: Evaluation

Refer to established outcomesRefer to established outcomes Evaluate individual’s condition and compare Evaluate individual’s condition and compare

actual outcomes with expected outcomesactual outcomes with expected outcomes Summarize results of evaluationSummarize results of evaluation Identify reasons for failure to achieve Identify reasons for failure to achieve

expected outcomesexpected outcomes Take corrective action to modify plan of careTake corrective action to modify plan of care Document evaluation in plan of careDocument evaluation in plan of care



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Critical ThinkingCritical Thinking

Identifying AssumptionsIdentifying Assumptions Recognize information taken for granted or fact Recognize information taken for granted or fact

without evidence for itwithout evidence for it Organized approachOrganized approach

Use an organized, systematic assessment formatUse an organized, systematic assessment format ValidationValidation

Check and corroborate accuracy and reliability of Check and corroborate accuracy and reliability of datadata

Normal and abnormalNormal and abnormal DistinguishDistinguish when identifying signs and symptoms when identifying signs and symptoms



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Critical Thinking (cont.)Critical Thinking (cont.)

Inferences or drawing valid conclusionsInferences or drawing valid conclusions Interpreting data and deriving correct conclusionsInterpreting data and deriving correct conclusions

Clustering related cuesClustering related cues Assists seeing relationships among dataAssists seeing relationships among data

RelevanceRelevance Look at clusters of data and consider which are Look at clusters of data and consider which are

important for health problemimportant for health problem InconsistenciesInconsistencies

Recognize subjective data at odds with objective Recognize subjective data at odds with objective datadata



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Identify patternsIdentify patterns Helps to see whole picture and discover missing Helps to see whole picture and discover missing

pieces of informationpieces of information

Missing informationMissing information Identify gaps in data or need for more specific Identify gaps in data or need for more specific

interviewing or laboratory data to make diagnosisinterviewing or laboratory data to make diagnosis

Health promotionHealth promotion Identify and manage known risk factors for Identify and manage known risk factors for

individual’s age group and cultural statusindividual’s age group and cultural status



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Risk diagnosisRisk diagnosis Identify actual and potential risks from full list of Identify actual and potential risks from full list of

both medical and nursing assessment databoth medical and nursing assessment data Set prioritiesSet priorities

When there is more than one diagnosis:When there is more than one diagnosis:• First-level priority problems: emergent, life threatening, First-level priority problems: emergent, life threatening,

and immediateand immediate

• Second-level priority problems: next in urgencySecond-level priority problems: next in urgency

• Third-level priority problems: important to patient’s health Third-level priority problems: important to patient’s health but can be addressed after more urgent problems are but can be addressed after more urgent problems are addressedaddressed



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Collaborative problemsCollaborative problems When approach to treatment involves multiple When approach to treatment involves multiple

disciplinesdisciplines

OutcomesOutcomes DetermineDetermine patient-centered expected outcomespatient-centered expected outcomes

• Specific, measurable, results expected to improve Specific, measurable, results expected to improve person’s problem after treatmentperson’s problem after treatment

• Outcome statements include specific time frameOutcome statements include specific time frame



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InterventionsInterventions DetermineDetermine specific interventionsspecific interventions that will achieve that will achieve

expected outcomes expected outcomes • Interventions aim to prevent, manage, or resolve health Interventions aim to prevent, manage, or resolve health

problemsproblems

• This is the health care planThis is the health care plan

Evaluation and corrective thinkingEvaluation and corrective thinking Analyze outcomes and apply them for evaluationAnalyze outcomes and apply them for evaluation

• Do stated outcomes match individual’s actual progress? Do stated outcomes match individual’s actual progress?

• Continually think, “what could be done differently or Continually think, “what could be done differently or better?”better?”



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Comprehensive plan of careComprehensive plan of care Evaluate and update planEvaluate and update plan Record revised plan and keep it up-to-dateRecord revised plan and keep it up-to-date Communicate revised plans to multidisciplinary Communicate revised plans to multidisciplinary

teamteam Be aware this is a legal document, and accurate Be aware this is a legal document, and accurate

recording is important for evaluation, insurance recording is important for evaluation, insurance reimbursement, and researchreimbursement, and research



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USING A CONCEPTUAL USING A CONCEPTUAL FRAMEWORK AS A GUIDE FRAMEWORK AS A GUIDE

Data base: organization of assessment data Data base: organization of assessment data varies depending on conceptual model usedvaries depending on conceptual model used Models provide a framework for:Models provide a framework for:

• Determining what to observeDetermining what to observe

• Organizing observations or dataOrganizing observations or data

• Interpreting and using the informationInterpreting and using the information

Nursing diagnoses are clinical judgments Nursing diagnoses are clinical judgments about a person’s response to an actual or about a person’s response to an actual or potential health statepotential health state



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EXPANDING THE CONCEPT OF EXPANDING THE CONCEPT OF HEALTHHEALTH

Assessment: collection of data about an Assessment: collection of data about an individual’s health stateindividual’s health state

A clear idea of health is important because it A clear idea of health is important because it determines assessment data to be collecteddetermines assessment data to be collected



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EXPANDING THE CONCEPT OF EXPANDING THE CONCEPT OF HEALTH (cont.)HEALTH (cont.)

Biomedical modelBiomedical model Health as absence of diseaseHealth as absence of disease Health and disease are opposite extremes on Health and disease are opposite extremes on

linear continuumlinear continuum Disease is caused by specific agents or pathogensDisease is caused by specific agents or pathogens A natural progression to health promotion and A natural progression to health promotion and

disease prevention rounds out our concept of disease prevention rounds out our concept of healthhealth

Guidelines to prevention emphasize link between Guidelines to prevention emphasize link between health and personal behaviorhealth and personal behavior



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Collecting Four Types of DataCollecting Four Types of Data

Complete total health data baseComplete total health data base Includes complete health history and full physical Includes complete health history and full physical

examinationexamination Describes current and past health state and forms Describes current and past health state and forms

baseline to measure all future changes baseline to measure all future changes Yields first diagnosesYields first diagnoses



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Collecting Four TypesCollecting Four Types of Data (cont.) of Data (cont.)

Episodic or problem-centered data baseEpisodic or problem-centered data base For limited or short-term problemsFor limited or short-term problems Collect “mini” data base, smaller scope and more Collect “mini” data base, smaller scope and more

focused than complete data basefocused than complete data base Concerns mainly one problem, one cue complex, Concerns mainly one problem, one cue complex,

or one body systemor one body system History and examination follow direction of History and examination follow direction of

presenting concernpresenting concern• Acute or chronic onset, associated with fever, local or Acute or chronic onset, associated with fever, local or

generalized generalized



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Follow-up data baseFollow-up data base Status of all identified problems should be Status of all identified problems should be

evaluated at regular and appropriate intervalsevaluated at regular and appropriate intervals Note changes that have occurred Note changes that have occurred Evaluate whether problem is getting better or Evaluate whether problem is getting better or

worseworse Identify coping strategies being usedIdentify coping strategies being used



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Emergency data baseEmergency data base Rapid collection of data, often compiled Rapid collection of data, often compiled

concurrently with lifesaving measuresconcurrently with lifesaving measures Diagnosis must be swift and sureDiagnosis must be swift and sure

• Person is questioned simultaneously while his or her Person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, airway, breathing, circulation, level of consciousness, and disability are being assessedand disability are being assessed



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FREQUENCY OF ASSESSMENTFREQUENCY OF ASSESSMENT

Interval of assessment varies with illness and Interval of assessment varies with illness and wellness needswellness needs Ill people seek care because of pain or abnormal Ill people seek care because of pain or abnormal

signs and symptomssigns and symptoms This prompts an assessment: gathering complete, This prompts an assessment: gathering complete,

episodic, or emergency data baseepisodic, or emergency data base

• Screening history for dietary intake, physical activity, Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practicestobacco/alcohol/drug use, and sexual practices

• Counseling for injury prevention, substance use, sexual Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental healthbehavior, diet and exercise, and dental health



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FREQUENCY OFFREQUENCY OFASSESSMENT (cont.)ASSESSMENT (cont.)

Routine periodic examination might include Routine periodic examination might include following services for preventive health care:following services for preventive health care: Screening history for dietary intake, physical Screening history for dietary intake, physical

activity, tobacco/alcohol/drug use, and sexual activity, tobacco/alcohol/drug use, and sexual practicespractices

Counseling for injury prevention, substance use, Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental sexual behavior, diet and exercise, and dental healthhealth

Immunizations Immunizations Chemoprophylaxis for multivitamin with folic acid Chemoprophylaxis for multivitamin with folic acid

for females capable of or planning pregnancyfor females capable of or planning pregnancy



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FREQUENCY OFFREQUENCY OFASSESSMENT (cont.)ASSESSMENT (cont.)

For well persons, opinions are changing For well persons, opinions are changing about assessment intervalsabout assessment intervals Annual checkup is vague: What does it constitute? Annual checkup is vague: What does it constitute?

Is it necessary? Does it sometimes give an implicit Is it necessary? Does it sometimes give an implicit promise of health and thus provide false security?promise of health and thus provide false security?

Timing of formerly accepted procedures is now Timing of formerly accepted procedures is now variable: for example, annual Papanicolaou testsvariable: for example, annual Papanicolaou tests

Same annual routine physical examination cannot Same annual routine physical examination cannot be recommended for all persons because health be recommended for all persons because health priorities vary among individuals, age groups, and priorities vary among individuals, age groups, and risk categoriesrisk categories



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ASSESSMENT THROUGHASSESSMENT THROUGHTHE LIFE CYCLETHE LIFE CYCLE

Age-specific charts for periodic health Age-specific charts for periodic health examinations are a positive approach to examinations are a positive approach to health assessmenthealth assessment Define lifetime schedule of health care, organized Define lifetime schedule of health care, organized

into packages for four specific age-groupsinto packages for four specific age-groups Each chart lists a frequency schedule for periodic Each chart lists a frequency schedule for periodic

health visits and preventive services for age grouphealth visits and preventive services for age group• These services include screening factors to gather These services include screening factors to gather

during the history, and age-specific items for physical during the history, and age-specific items for physical examination and laboratory procedures, counseling examination and laboratory procedures, counseling topics, and immunizationstopics, and immunizations



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ASSESSMENT THROUGHASSESSMENT THROUGHTHE LIFECYCLE (cont.)THE LIFECYCLE (cont.)

Age-specific charts focus on major risk Age-specific charts focus on major risk factors specific for each age group based on factors specific for each age group based on lifestyle, health needs, and problems lifestyle, health needs, and problems Shift emphasis from an annual physical Shift emphasis from an annual physical

examination toward rational and varying periodicityexamination toward rational and varying periodicity Incorporate health promotion and disease Incorporate health promotion and disease

prevention at every health visit, not just at one prevention at every health visit, not just at one annual physical examinationannual physical examination

Health education and counseling are highlighted Health education and counseling are highlighted as means to deliver health promotionas means to deliver health promotion



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CROSS-CULTURAL CARECROSS-CULTURAL CARE

A holistic model of health care assessment A holistic model of health care assessment must include culturemust include culture

Inclusion of heritage assessment is of Inclusion of heritage assessment is of paramount importance to gather meaningful paramount importance to gather meaningful data and intervene with culturally sensitive data and intervene with culturally sensitive and appropriate careand appropriate care With the rapid increases in numbers of individuals With the rapid increases in numbers of individuals

from diverse cultural backgrounds in the U.S., a from diverse cultural backgrounds in the U.S., a concern for cultural beliefs and practices of people concern for cultural beliefs and practices of people is increasingly important in health careis increasingly important in health care



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CROSS-CULTURALCROSS-CULTURALCARE (cont.)CARE (cont.)

A serious conceptual problem arises as A serious conceptual problem arises as nurses and physicians are expected to know, nurses and physicians are expected to know, understand, and meet health needs of people understand, and meet health needs of people from culturally diverse backgrounds without from culturally diverse backgrounds without formal preparation for doing soformal preparation for doing so

International interchanges are increasing International interchanges are increasing among nurses and physicians, making among nurses and physicians, making attention to cultural aspects of health and attention to cultural aspects of health and illness an even greater priorityillness an even greater priority



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HIGH-LEVELHIGH-LEVELASSESSMENT SKILLSASSESSMENT SKILLS

Attention to life cycle, holism, and culture Attention to life cycle, holism, and culture must not detract from importance of must not detract from importance of assessment skills themselvesassessment skills themselves

Assessment skills require hands-on expertise Assessment skills require hands-on expertise refined to a high levelrefined to a high level Nurse is first and often only health professional to Nurse is first and often only health professional to

see an individual in many communitiessee an individual in many communities Nurse is only health professional continually Nurse is only health professional continually

present at bedside in hospitalspresent at bedside in hospitals



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HIGH-LEVELHIGH-LEVELASSESSMENT SKILLS (cont.)ASSESSMENT SKILLS (cont.)

Efforts at cost containment result in hospital Efforts at cost containment result in hospital populations composed of people with populations composed of people with increased acuity, shorter stays, and earlier increased acuity, shorter stays, and earlier discharges than in pastdischarges than in past Nurses must make faster, more efficient Nurses must make faster, more efficient

assessmentsassessments Nurses required go to people’s homes for follow-Nurses required go to people’s homes for follow-

up assessment and diagnosisup assessment and diagnosis First-rate assessment skills grounded in holistic First-rate assessment skills grounded in holistic

approach and knowledge of age-specific problems approach and knowledge of age-specific problems are requiredare required

Chapter 1

Healthcare

Transcript of Chapter 1