1. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Evidence-Based Assessment Chapter 1

2. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-2 Assessment: Point of Entry in an Ongoing Process  Subjective data  What patient says about himself or herself during history taking  Objective data  Observed when inspecting, percussing, palpating, and auscultating patient during physical examination  Data base  Formed from these elements, plus patient’s record and laboratory studies

3. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-3 Clinical Reasoning Models  Diagnostic reasoning  Nursing process  Critical thinking

4. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-4 Diagnostic Reasoning  Attend to initially available cues  Cue: piece of information, sign, symptom, or piece of laboratory data  Formulate diagnostic hypotheses  Hypothesis: tentative explanation for cues used as a basis for further investigation  Gather data relative to tentative hypotheses  Evaluate each hypothesis with new data collected to arrive at final diagnosis

5. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-5 Nursing Process  Assessment  Diagnosis  Outcome identification  Planning  Implementation  Evaluation

6. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-6 Nursing Process: Assessment  Collect data  Review of clinical record  Interview  Health history  Physical examination  Functional assessment  Cultural and spiritual assessment  Consultation  Review of the literature

7. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-7 Nursing Process: Diagnosis  Interpret data  Identify clusters of cues  Make inferences  Validate inferences  Compare clusters of cues with definitions and defining characteristics  Identify related factors  Document the diagnosis

8. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-8 Nursing Process: Outcome Identification  Identify expected outcomes  Individualize to patient  Ensure outcomes are realistic and measurable  Include a time frame

9. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-9 Nursing Process: Planning  Establish priorities  Develop outcomes  Set time frames for outcomes  Identify interventions  Document plan of care

10. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-10 Nursing Process: Implementation  Determine patient readiness  Review planned interventions  Collaborate with other team members  Supervise by delegating appropriate responsibilities  Counsel person and significant others  Involve person in health care  Refer for continuing care  Document care provided

11. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-11 Nursing Process: Evaluation  Refer to established outcomes  Evaluate individual’s condition and compare actual outcomes with expected outcomes  Summarize results of evaluation  Identify reasons for failure to achieve expected outcomes  Take corrective action to modify plan of care  Document evaluation in plan of care

12. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-12 Critical Thinking  Identifying Assumptions  Recognize information taken for granted or fact without evidence for it  Organized approach  Use an organized, systematic assessment format  Validation  Check and corroborate accuracy and reliability of data  Normal and abnormal  Distinguish when identifying signs and symptoms

13. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-13 Critical Thinking (cont.)  Inferences or drawing valid conclusions  Interpreting data and deriving correct conclusions  Clustering related cues  Assists seeing relationships among data  Relevance  Look at clusters of data and consider which are important for health problem  Inconsistencies  Recognize subjective data at odds with objective data

14. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-14 Critical Thinking (cont.)  Identify patterns  Helps to see whole picture and discover missing pieces of information  Missing information  Identify gaps in data or need for more specific interviewing or laboratory data to make diagnosis  Health promotion  Identify and manage known risk factors for individual’s age group and cultural status

15. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-15 Critical Thinking (cont.)  Risk diagnosis  Identify actual and potential risks from full list of both medical and nursing assessment data  Set priorities  When there is more than one diagnosis: First-level priority problems: emergent, life threatening, and immediate First-level priority problems: emergent, life threatening, and immediate Second-level priority problems: next in urgency Second-level priority problems: next in urgency Third-level priority problems: important to patient’s health but can be addressed after more urgent problems are addressed Third-level priority problems: important to patient’s health but can be addressed after more urgent problems are addressed

16. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-16 Critical Thinking (cont.)  Collaborative problems  When approach to treatment involves multiple disciplines  Outcomes  Determine patient-centered expected outcomes Specific, measurable, results expected to improve person’s problem after treatment Specific, measurable, results expected to improve person’s problem after treatment Outcome statements include specific time frame Outcome statements include specific time frame

17. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-17 Critical Thinking (cont.)  Interventions  Determine specific interventions that will achieve expected outcomes Interventions aim to prevent, manage, or resolve health problems Interventions aim to prevent, manage, or resolve health problems This is the health care plan This is the health care plan  Evaluation and corrective thinking  Analyze 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 better?” Continually think, “what could be done differently or better?”

18. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-18 Critical Thinking (cont.)  Comprehensive plan of care  Evaluate and update plan  Record revised plan and keep it up-to-date  Communicate revised plans to multidisciplinary team  Be aware this is a legal document, and accurate recording is important for evaluation, insurance reimbursement, and research

19. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-19 USING A CONCEPTUAL FRAMEWORK AS A GUIDE  Data base: organization of assessment data varies depending on conceptual model used  Models provide a framework for: Determining what to observe Determining what to observe Organizing observations or data Organizing observations or data Interpreting and using the information Interpreting and using the information  Nursing diagnoses are clinical judgments about a person’s response to an actual or potential health state

20. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-20 EXPANDING THE CONCEPT OF HEALTH  Assessment: collection of data about an individual’s health state  A clear idea of health is important because it determines assessment data to be collected

21. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-21 EXPANDING THE CONCEPT OF HEALTH (cont.)  Biomedical model  Health as absence of disease  Health and disease are opposite extremes on linear continuum  Disease is caused by specific agents or pathogens  A natural progression to health promotion and disease prevention rounds out our concept of health  Guidelines to prevention emphasize link between health and personal behavior

22. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-22 Collecting Four Types of Data  Complete total health data base  Includes complete health history and full physical examination  Describes current and past health state and forms baseline to measure all future changes  Yields first diagnoses

23. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-23 Collecting Four Types of Data (cont.)  Episodic or problem-centered data base  For limited or short-term problems  Collect “mini” data base, smaller scope and more focused than complete data base  Concerns mainly one problem, one cue complex, or one body system  History and examination follow direction of presenting concern Acute or chronic onset, associated with fever, local or generalized Acute or chronic onset, associated with fever, local or generalized

24. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-24 Collecting Four Types of Data (cont.)  Follow-up data base  Status of all identified problems should be evaluated at regular and appropriate intervals  Note changes that have occurred  Evaluate whether problem is getting better or worse  Identify coping strategies being used

25. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-25 Collecting Four Types of Data (cont.)  Emergency data base  Rapid collection of data, often compiled concurrently with lifesaving measures  Diagnosis must be swift and sure Person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed Person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed

26. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-26 FREQUENCY OF ASSESSMENT  Interval of assessment varies with illness and wellness needs  Ill people seek care because of pain or abnormal signs and symptoms  This prompts an assessment: gathering complete, episodic, or emergency data base Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health

27. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-27 FREQUENCY OF ASSESSMENT (cont.)  Routine periodic examination might include following services for preventive health care:  Screening history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices  Counseling for injury prevention, substance use, sexual behavior, diet and exercise, and dental health  Immunizations  Chemoprophylaxis for multivitamin with folic acid for females capable of or planning pregnancy

28. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-28 FREQUENCY OF ASSESSMENT (cont.)  For well persons, opinions are changing about assessment intervals  Annual checkup is vague: What does it constitute? Is it necessary? Does it sometimes give an implicit promise of health and thus provide false security?  Timing of formerly accepted procedures is now variable: for example, annual Papanicolaou tests  Same annual routine physical examination cannot be recommended for all persons because health priorities vary among individuals, age groups, and risk categories

29. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-29 ASSESSMENT THROUGH THE LIFE CYCLE  Age-specific charts for periodic health examinations are a positive approach to health assessment  Define lifetime schedule of health care, organized into packages for four specific age-groups  Each chart lists a frequency schedule for periodic health visits and preventive services for age group These services include screening factors to gather during the history, and age-specific items for physical examination and laboratory procedures, counseling topics, and immunizations These services include screening factors to gather during the history, and age-specific items for physical examination and laboratory procedures, counseling topics, and immunizations

30. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-30 ASSESSMENT THROUGH THE LIFECYCLE (cont.)  Age-specific charts focus on major risk factors specific for each age group based on lifestyle, health needs, and problems  Shift emphasis from an annual physical examination toward rational and varying periodicity  Incorporate health promotion and disease prevention at every health visit, not just at one annual physical examination  Health education and counseling are highlighted as means to deliver health promotion

31. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-31 CROSS-CULTURAL CARE  A holistic model of health care assessment must include culture  Inclusion of heritage assessment is of paramount importance to gather meaningful data and intervene with culturally sensitive and appropriate care  With the rapid increases in numbers of individuals from diverse cultural backgrounds in the U.S., a concern for cultural beliefs and practices of people is increasingly important in health care

32. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-32 CROSS-CULTURAL CARE (cont.)  A serious conceptual problem arises as nurses and physicians are expected to know, understand, and meet health needs of people from culturally diverse backgrounds without formal preparation for doing so  International interchanges are increasing among nurses and physicians, making attention to cultural aspects of health and illness an even greater priority

33. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-33 HIGH-LEVEL ASSESSMENT SKILLS  Attention to life cycle, holism, and culture must not detract from importance of assessment skills themselves  Assessment skills require hands-on expertise refined to a high level  Nurse is first and often only health professional to see an individual in many communities  Nurse is only health professional continually present at bedside in hospitals

34. Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 1: Evidence-Based Assessment Slide 1-34 HIGH-LEVEL ASSESSMENT SKILLS (cont.)  Efforts at cost containment result in hospital populations composed of people with increased acuity, shorter stays, and earlier discharges than in past  Nurses must make faster, more efficient assessments  Nurses required go to people’s homes for follow- up assessment and diagnosis  First-rate assessment skills grounded in holistic approach and knowledge of age-specific problems are required