Evidenced Based Assessment Flashcards
What is the Nursing Process in order?
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Why is doing an assessment so important?
It is fundamental to the remainder of the process. All healthcare diagnoses, decisions, and treatments are based on the data gathered during assessment.
Where do we collect data from during assessment?
Review of the clinical record
Interviewing the patient
health history (from convo)
Physical exam
Functional Assessment (how they are functioning in daily life)
Consultation
Review of the literature
What is subjective data?
what the patient tells you.
what kind of data is pain?
Subjective data.
What is objective data?
what you assess through physical and mental assessment.
what kind of data is this?
Temperature: 37.4
Pulse: 64
Respirations: 15
SPO2: 97%
Objective data
What kind of data is laboratory data?
Objective Data
Ex.The patients medical record
What is the purpose of assessment?
To formulate a a clinical judgement or diagnosis about the patient’s health state
What kind of data do we need to formulate a diagnosis?
subjective data
objective data
patient’s record
laboratory studies
Review of literature
Think of it as an equation.
What is factually based data and evidenced-based data free of?
Free of assumptions and biases
What is diagnostic reasoning?
Process of analyzing data and drawing conclusions to identify diagnoses
What are cues?
pieces of information gathered that show an abnormal sign or altered health state.
These clues could also be pieces of information gathered leading to normal findings
What are clusters?
The grouping together of cues.
What are the 3 things to do when interpreting data collected?
Cluster or group together cues
look for patterns
make inferences
What should you do with data collected, especially abnormal data?
Validate it. Always.
What are the components of diagnostic reasoning?
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.
*serves as a basis for ongoing investigation
What is required for sound diagnostic reasoning and clinical judgment?
Critical thinking
What are the three dimensions of critical thinking
Theory and Experiential Knowledge to perform the nursing process
commitment to learning to think critically
psychomotor and manual skill development
What are first priority?
ABC
Airway
Breathing
Circulation
What are second level priorities?
Acute pain
Change in mental status
Infection
What are third level priorities?
Are important to patient’s health but can be addressed after more urgent problems.
Lack of knowledge
Family coping
activity
rest
What are the four types of databases?
Complete (total health)
episodic or problem-centered
Follow-up
Emergency
What is a complete (total health) database?
A full examination of every body system; head-to-toe assessment.
What is episodic (problem-centered) data base?
Focuses on only one body system that is having a problem.
What is follow-up data?
Following up on a health issue that was previously addressed or treated.
What is an emergency database?
life or death assessment. Focused especially on one body system to prevent fatal outcomes.
ex. A patient comes in with an open hemorrhage of the femoral artery. Focused on stopping the bleeding and nothing else.
What is evidenced based assessment?
Rooted in the belief that all patients deserve to be treated with the most current and best-practice techniques.
What is evidence-based practice?
A systematic approach to practice that emphasizes the use of best evidence.
What does evidence-based practice involve?
Integration of research evidence, clinical expertise, clinical knowledge, and patient values and preferences.
What are the 5 steps to evidence-based practice? (A’s)
Ask the clinical question
Acquire sources of evidence
appraise and synthesize evidence
apply relevant evidence in practice
Assess the outcomes
