Class 1-Evidence Based-Assessment Flashcards
Assessment: Data Collection
-the collection of data about an individual’s health state
-critical thinking is required for sound diagnostic reasoning and clinical judgement
-the PURPOSE of assessment is to make a judgement or diagnosis
Assessment: point of entry in an ongoing process
-subjective date + objective data + patient’s record, & laboratory studies form the database
-information from the database allows the nurse to make a clinical judgement or diagnosis about the patient’s health state
-key is organization of assessment based on complete factually based data
-subjective (what patient tells you)
-objective (what we’ll see)
Assessment: data collection
assessment is first step!
-history: subjective data
-physical exam: objective data
-what is the difference?
-what is the importance of data collection?
What are the 3 dimensions of critical thinking?
- theory and experiential knowledge to perform the nursing process
- commitment to learning to think critically
- psychomotor and manual skill development
-knowledge; compile knowledge; & perform
Assessment
-First step of the nursing process
-requires ability to gather data that is:
-accurate
-relevant
-differentiates normal and abnormal
-organized
-systematic
-complete
Nursing Process: Assessment
Collect data
-review of the clinical record
-interview
-health history
-physical exam
-functional assessment
-consultation
-review of the literature
So what are the steps in this assessment process?
-interpret data
-identify clusters of cues
-make inferences
-validate inferences
-compare clusters of cues with definitions and defining characteristics
-identify related factors
-establish a nursing diagnosis
Nursing process
-assessment, always the first step of the nursing process (collection of data; cues you take from pts)
-remaining steps of nursing process:
-diagnosis
-outcome identification
-planning
-implementation
-evaluation
Nursing Process
-assessment
-diagnosis
-outcome identification
-planning
-implementation
-evaluation
Data collection & first level priorities
-first level priority: emergent, life threatening, & immediate
-during assessment it is absolutely essential to have the ability to prioritize data
-these are always first level priorities, in this order:
-A-airway
-B-breathing
-C-circulation
Data collection & second level priorities
-next in urgency, requiring attention to avoid further deterioration
-these situations require prompt intervention to prevent further deterioration:
-acute pain
-change in mental status
-infection
^^urgent priority
Data collection & third level priorities
-these situations are important to the patient’s health but can be addressed after more urgent problems
-lack of knowledge
-family coping
-activity
-rest
^^preventative
How do we think critically about a situation?
Using case study…
-how does a person analyze health data and draw conclusions?
-what is a cue and how do I attend to it?
-what is a diagnostic hypothesis?
-how accurate are hunches?
-what cues are significant?
-what do I do with the cues once I have them?
-how do I validate that my hypothesis is correct?
-why is validation so important?
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 basis for ongoing investigation
What do novices do?
slow process, lacks experience, may not see the whole picture, follow more of a defined pattern, and sets of rules
