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EVIDENCE BASED ASSESSMENT •

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Subjective vs. Objective Data o Subj – what the person SAYS/information the patient provides ▪ Document in quotations o Obj – what YOU as the RN observe, do, and assess o Subj + Obj = your database o Ex: ▪ Subj: “My head hurts”, “I feel dizzy”, “I feel like my heart is racing”, “I fell off the ladder while hanging up Christmas lights” “Pain is 7/10”, ▪ Obj: right ankle has edema and a bruise approx.. 8cm x 8cm, 140 BPM heart rate, patient has tenderness in RLQ Diagnostic Reasoning o Process of analyzing data and coming up with conclusions for diagnosis o 4 components ▪ Attending: to initial cues • Look at what is available, what has the patient said, what have you read in the chart ▪ Formulating: formulate hypothesis • Diagnostic hypothesis “because the patient is experiencing this this and this, I believe that the patient has a nursing diagnosis of this” ▪ Gathering: gather data that is relative • If you want to prove the hypothesis what other info do you need to get ▪ Evaluating: evaluate and make final diagnosis • Evaluate each hypothesis with any new clues that are given at any time and eventually arrive at a final diagnosis ▪ Once you complete data collection, develop a preliminary list of significant signs and symptoms for all patient health needs this list will be less formal than your final list of diagnoses and is in no particular order ▪ Cluster or group together the assessment data that appear to be casual or associated ▪ Validate the data you collect to make sure they are accurate, as you validate data look for gaps in data collection and eliminate any extraneous variables o Sign vs. Symptom ▪ Sign is what you can see or observe about the patient (obj) ▪ Symptom is what the patient feels so what does it correlate to? (subj) ▪ Symptom-subjective sensation that a person feels from a disorder ▪ Sign-an objective abnormality that you as the examiner could detect on a physical exam or lab reports o Nursing Process: 6 phases – ADOPIE, review what each of these entails (pg.3) ▪ Assessment- collection of data, review of clinical record, interview, health history, physical exam, functional assessment (Social, ADL), consultation (PT), review of literature

▪ Diagnosis- interpret data, identify clues and related factors and make valid inferences. Document the diagnosis. Nursing diagnosis is related to symptoms and different than doctor diagnosis. NANDA- North American Nursing Diagnosis Association: ▪ Acute diagnosis- an existing problem ▪ Risk diagnosis- a potential for a problem developing (pt doesn’t have yet) ▪ Wellness diagnosis- focusing on the persons strengths to enhance and promote health ▪ Diagnostic reasoning model: focus on initial cues given by patient, formal a initial diagnostic hypothesis, gather information and evaluate hypothesis ▪ Planning/Outcome identification- identifies expected outcomes that are individualized to the person, establishes priorities and develops outcomes that are realistic and measurable with a set time frame, identify interventions and document care plan. SMART: Specific, Measurable, Attainable, Realistic/relevant, Time restricted Implementingphysical, verbal and collaborative. The care plan is supervised and ▪ patient and significant others are educated. The patient is involved in the care and all care is documented. ▪ Evaluation- evaluate patients conditions and compare to expected outcomes. Summarize evaluation, identify any failures and their reasonings. Correct or modify care plan if needed. Ex: “have things changed?” o Priority Problems: (pg.4) Table 1-1 ▪ First level – These problems are those that are emergent, life threatening and immediate such as establishing an airway or supporting breathing • ABCV’s ▪ Second level – Theses problems are those that are next in urgency – those requiring prompt intervention to prevent further deterioration (i.e. mental status change, acute urinary elimination problems, untreated medical problems, acute pain, chronic illness, abnormal lab work, risk for infection/safety/security) ▪ Third level – These are important to the patient’s health but can be addressed after more urgent health problems are addressed • Interventions to treat these problems are more long term and the response to treatment is expected to take more time • Need for teaching, activities, rest, coping, family issues ▪ Collaborative – multiple disciplines needed, diabetes treatment • Are problems in which the approach to treatment involves multiple disciplines • They are certain physiologic conditions in which nurses have the primary responsibility to diagnose the onset and monitor the changes in status Novicesomeone inexperienced with a specified patient population and uses rules to ▪ guide their performance ▪ Mastering this process takes time, perhaps 2-3 years in similar clinical situations to achieve competency, in which you see actions in the context of arching goals or daily plans for patients

▪ Competency takes 2-3 years, you see actions in the context of arching goals or daily plans for patients ▪ With more time and experience the proficient nurse understands a patient situation as a whole rather than as a list of tasks ▪ Expert nurses often vault over the steps and arrive at a clinical judgment in one leap and has an intuitive grasp of a clinical situation •

What are the 4 aspects to EBP? (pg.5) o The best evidence from a critical review of research literature o The patient’s own preferences o The clinician’s experience o Physical examination and assessment

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Types of Data (pg.6-7) o Complete Database – complete health history + full physical ▪ Current and past health ▪ Used as a baseline, collected often by primary care ▪ Screens and refer ▪ Done on admission in hospital o Focused/Problem Centered Database – particular problem/one system ▪ Takes recent history to focus on acute problem o Follow-up Database ▪ Follows up on acute or chronic problems • What change has occurred? • Getting better or worse? • What coping strategies are used? o Emergency Database ▪ Urgent collection of relevant data ▪ Do you care about the entire family history of a patient who is coming in with potential spine injury and lacerations from falling off a ladder? NO, not really. You care about how did this happen? Do they have allergies? What’s his breathing pattern? BP? Pulse? Total: o Includes a complete health history and a full physical examination o It describes the current and past health state and forms a baseline against which all future changes can be measured o It yields the first diagnosis o It is often collected in a primary care setting such as a pediatric or family practice clinic, independent or group private practice, college health service, women’s health care agency, visiting nurse agency or community health agency ! when you work in these settings, you are the first health professional to see the patient and have primary responsibility for monitoring the person’s health care

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o Collecting the complete database is an opportunity to build and strengthen your relationship with the patient o For well and ill people, the complete database must screen for pathology and determine the ways people respond to that pathology or to any health problem Focused or Problem Centered: o For a limited or short term problem o You collect a mini database that is more targeted than the complete database o It concerns mainly one problem, one cue complex or one body system o It is used in all settings Follow up: o The status of any identified problems should be evaluated at regular and appropriate intervals o What change has occurred? Is the problem-getting better or worse? Which coping strategies are used? This database is used in all settings to follow up both short term and long term (chronic) health problems Emergency: o This is urgent, rapid collection of crucial information and often is compiled concurrently with life saving measures o Diagnosis must be swift and sure o First history questions are: What did you take? How much did you take? When? o The person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness and disability are being assessed o Once the person has been stabilized, a complete database can be complied

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Holistic health- views the mind body and spirit as interdependent and functioning as a whole within the environment

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The basis of disease is multifaceted, originating from both within the person and from the external environment

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Health promotion and disease prevention form the core of nursing practice Prevention of disease can be achieved through counseling from primary care providers

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Guide to clinical preventive services- positive approach to health assessment reduction. Updated annually and accessible online or in print. Presents evidence based gold standard recommendations on screening counseling and preventive topics and includes clinical considerations for each topic o To know the recent screening methods of disorders o To locate the various health counseling strategies o To identify preventative measures of various disorders...