Evidence-Based Assessment

• Major Areas of Subjective data

  • Biographical information: name, age, religion, address, birthday, birthplace, occupation
  • Physical symptoms related to each body part
  • Past health history
  • Family history
  • Health and lifestyle practices that put the client at risk: nutrition, activity
• The end result of a nursing assessment is the formulation of nursing diagnoses (wellness, risk or actual) that require nursing care, the need for collaborative care, and the identification of medical problems that need immediate referral
• Hypothetico-deductive process


  1. Attending to initially available cues

  2. Formulating diagnostic hypotheses

  3. Gathering data relative to the tentative hypotheses

  4. Evaluating each hypothesis with the new data collected thus arriving at a final diagnosis
• Health Assessment


  1. Collect subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment

  2. Establish a database
• Diagnostic Reasoning


  Analyzing health data and drawing conclusions to identify diagnoses
• Collecting Subjective Data

  1. Sensations or symptoms: pain, hunger, dizziness

  2. Feelings: happiness, sadness

  3. Perceptions, desires, preferences, beliefs, ideas, values, and personal information
• Priority Setting


  As the nurse gathers clinical cues and completes an assessment, priority setting should be done as follows: First level priority problems, Second level priority problems, Third level priority problems
• Types of data collected

  • Subjective Data (symptoms)
  • Objective Data (signs)
• Diagnostic Reasoning

  1. A cue is a piece of information, a sign or symptom, or a piece of laboratory data

  2. A hypothesis is a tentative explanation for a cue or set of cues that can be used as a basis for further investigation
• Collecting Objective data

  1. Physical characteristics (posture, gait, skin color)

  2. Body functions: heart rate, pulse rate

  3. Appearance: dress and hygiene

  4. Behavior: mood, affect

  5. Measurements: BP, Temperature, height, abdominal girth, head circumference, chest circumference, length, weight

  6. Results of laboratory testing: CBC, X-ray, ultrasound
• Four types of data: Focused or Problem-Centered Database


  • For a limited or short-term purpose
• Evidence-Based Assessment


  A systematic approach that emphasizes the use of best evidence, clinician's experiences, patient preferences, and values to make decisions about care and treatment
• Four types of data: Complete database


  • Includes a complete health history and full examination, describes current and past health status, collected in a primary care setting
• Clinical decision making depends on four factors: best evidence, patient's preference, clinician's experience, physical examination and assessment
• Four types of data

  • Complete database
  • Focused or problem-centered database
  • Follow up database
  • Emerging database
• Priority Setting

  1. First level priority problems

  2. Second level priority problems

  3. Third level priority problems

  4. Collaborative problems
• Four types of data: Complete database for a well person

  • Describes health status, perception of health, strengths or assets, risks factors, and lifestyle changes
• FOCUSED OR PROBLEM CENTERED DATABASE

  • 2 days post-op, a hospitalized patient suddenly has a congested cough, SOB, and fatigue
• Communication

  1. Channel through which intervention is carried out

  2. Involves all behavior, conscious and unconscious, verbal and non-verbal
• FOCUSED OR PROBLEM CENTERED DATABASE

  • For a limited or short-term problem
  • Mainly focuses on one problem, one cue, or one body system
• Non-Verbal Communication


  • Appearance, demeanor, facial expression, attitude, silence, listening
• EMERGING DATABASE


  • A person brought into a hospital emergency department with a suspected substance overdose
• EMERGING DATABASE


  • Urgent, rapid collection of crucial information
  • Compiled concurrently with lifesaving measures
  • Diagnosis must be swift and sure
• Types of Data

  1. FOCUSED OR PROBLEM CENTERED DATABASE

  2. FOLLOW UP DATABASE

  3. EMERGING DATABASE
• FOLLOW UP DATABASE

  • Evaluates the status of any identified problem at regular and appropriate intervals
  • Aims to assess changes, whether the problem is improving or worsening, and coping strategies used
• Interview


  Main purpose is to encourage information exchange between the patient and the nurse
• Verbal Communication


  • Open-ended questions, closed-ended questions, laundry list, rephrasing, well-placed phrases
• Inferring


  If used properly helps to elicit the most accurate data possible from the client
• Feelings to choose from in describing symptoms, conditions, or feelings

  • Rephrasing
  • Well placed phrases
  • Inferring
• Introductory Phase

  1. Introducing oneself to the client and relative as well

  2. Explains the purpose of the interview

  3. Discusses the types of questions that will be asked

  4. Explains the reason for taking notes

  5. Assures confidentiality

  6. Makes the client comfortable

  7. Maintains client's privacy
• Phases of Interview

  1. Interviewing

  2. Preintroductory/Preparatory Phase

  3. Introductory Phase

  4. Working/Maintenance Phase

  5. Summary/Closing or Concluding Phase
• Empathy


  Feeling with the person rather than feeling like the person
• Liking other


  One essential factor in a helping relationship, like nursing, is a genuine liking of other people. An atmosphere of warmth and caring is necessary. The patient must feel that he or she is accepted
• Empathy


  Viewing the world from the other person's inner frame of reference while remaining oneself. It also means recognizing and accepting the other person's feelings without criticism
• Well placed phrases


  Listen closely to the client during their description and use phrases such as "um-hum", "yes", or "I agree" to encourage the client to continue
• Summary/Closing or Concluding Phase

  1. The nurse summarizes information obtained during the working phase

  2. Validates problems and goals with the client

  3. Discusses possible plans to resolve the problem with the client

  4. Also known as "termination phase"
• Preintroductory/Preparatory Phase


  1. The nurse reviews the medical record before meeting with the client

  2. To ensure that the interview will be as productive as possible
• Rephrasing


  1. Helps the nurse to clarify information the client has stated

  2. Enables the nurse and the client to reflect on what was said
• Interviewing

  1. Vital for accurate collection of subjective data

  2. Requires professional, interpersonal, and interviewing skills
• Working/Maintenance Phase

  1. The nurse elicits the client's comments about major biographic data

  2. Reasons for seeking care

  3. History of present and past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level

  4. The nurse listens, observes cues and uses critical thinking skills to interpret and validate information received from the client

  5. The nurse and client collaborate to identify the client's problems and goals