CH 1: Evidence Based Assessment Flashcards
Purpose of assessment?
To make clinical judgement or diagnosis
required for sound diagnostic reasoning and clinical judgement?
critical thinking
Subjective data?
How the patient feels
Objective data?
What we can observe
What are the 3 dimensions of critical thinking?
- Theory and experimental knowledge to perform nursing process
- Commitment to learning to think critically
- Psychomotor and manual skill development
What is the Nursing Process?
ADPIE
Assessment
Diagnosis (or interpretation of findings)
Planning
Implementation
Evaluation
Nursing Process meaning?
Assessment: Collect and document relevant data
Diagnosis: Compare clinical findings, interpret data (cluster cues), validate and document diagnoses
Planning: Establish priorities and develop outcomes, plan of care
Implementation: Take action
Evaluation: Progress towards outcome, reassess as needed
Assessment data requirements?
Accurate
Relevant
Organized
Systematic
Differentiates normal and abnormal
Complete
Process of data collection?
Review clinical record
Interview
Health history
Physical exam
Functional assessment
Consultation
Literature review
First level priority?
Emergent, immediate, and life threatening
ABC’s
Airway
Breathing
Circulation
Second level priority?
Requires attention to avoid further deterioration
Acute pain
Mental status changes
Infection
Third level priority?
Important to health but addressed after urgent problems
Lack of knowledge
Family coping
Activity
Rest
Diagnostic reasoning components?
Attend to initially available cues (pieces of information)
Formulate diagnostic hypotheses (tentative explanation of cues)
Gather relevant data
Evaluate each hypothesis with ongoing data collection
Serve as a basis for ongoing investigation
Novice nursing?
Slow process, lacks experience, may not see whole picture, follows defined pattern and sets of rules
Expert nurse?
Uses intuition, recognizes patterns, able to draw conclusions from cues quickly and act on them
