Physical Assesment

• Evidence-Based Assessment


  The collection of data about the individual's health state
• Expectations of provider


  Establish an open and honest relationship, listen to her needs and facilitate her health goals
• Findings from physical examination

  • Normocephalic, face symmetric
  • Vision tested annually, wears corrective lenses since 4th grade
  • Scarring of bilateral tympanic membranes, denies hearing problems
  • Gums pink, 3 noticeable fillings, no dental pain
  • Compound nevus on left inner elbow
  • Breath sounds clear and equal bilaterally, heart S1S2 normal
  • Abdomen rounded, bowel sounds present, reports BM daily
  • Extremities warm and equal bilaterally, all pulses present and equal
  • Sensory modalities intact in legs and feet, no lesions
• The examiner analyzed and interpreted all the data, clustered the information, and identified the diagnoses
• Assessment


  The collection of data about the individual's health state
• Diagnostic reasoning


  The process of analyzing health data and drawing conclusions to identify diagnoses
• Components of hypothetico-deductive diagnostic reasoning

  • Attending to initially available cues
  • Formulating diagnostic hypotheses
  • Gathering data relative to the tentative hypotheses
  • Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis
• Cue


  A piece of information, a sign or symptom, or a piece of laboratory or imaging data
• Hypothesis


  A tentative explanation for a cue or a set of cues that can be used as a basis for further investigation
• Developing a preliminary list of significant signs and symptoms for all patient health needs is less formal in structure than the final list of diagnoses
• Clustering data


  Grouping together assessment data that appear to be causal or associated
• Experienced examiners cluster data more rapidly because they recall proven results of earlier patient situations and recognize the same patterns in the new clinical situation
• Validating data is an essential critical-thinking skill to ensure accuracy
• Critical thinking


  The means by which we learn to assess and modify, if indicated, before acting
• Critical thinking is required for sound diagnostic reasoning and clinical judgment
• Rates of incorrect diagnoses are estimated to be as high as 10% to 15%, and one of the primary causes of misdiagnosis is the clinician's bias
• Priority setting


  Assigning high priority to first-level problems like airway, breathing, and circulation, then second-level problems like mental status changes and abnormal lab values, and finally third-level problems like lack of knowledge and mobility issues
• Patients often require the assistance of an interdisciplinary team of practitioners to treat complex medical problems
• Outcomes need to be measurable and include patient input to facilitate active participation in care
• Interventions to treat complex medical problems

  1. Long term

  2. Require collaborative effort between patient and health care professionals
• Health is complex and requires input from a variety of specialties (e.g., physical therapy, speech therapy, occupational therapy)
• Patients are more likely to participate actively in care and follow through with recommendations if they are part of developing the plan of care
• Critical-thinking process


  1. Evaluation

  2. Planning
• Accurate recording is important for evaluation, insurance reimbursement, and research
• Evidence-based practice (EBP) is more than the use of best-practice techniques to treat patients
• Evidence-based practice


  The integration of research evidence, clinical expertise, clinical knowledge (physical assessment), and patient values and preferences
• Clinical decision making depends on all four factors: the best evidence from a critical review of research literature; the patient's own preferences; the clinician's own experience and expertise; and finally physical examination and assessment
• Assessment skills must be practiced with hands-on experience and refined to a high level
• It is important to question tradition when no compelling research evidence exists to support it
• Some time-honored assessment techniques have been removed from the examination repertoire because clinical evidence indicates that these techniques are not as accurate as once believed
• Steps to evidence-based practice

  1. Ask an evidence-based question

  2. Gather best research evidence through a literature search

  3. Appraise the evidence to identify better treatment or assessment approach

  4. Institute a new practice protocol and monitor patient outcomes
• Research led to a change of clinical practice that was safe, effective, and efficient
• Evidence shows that other assessment skills are effective for patient care, such as measuring the ankle brachial index (ABI)
• It often takes up to 17 years for research findings to be implemented into practice
• Barriers to evidence-based practice

  • Nurses lack research skills in evaluating quality of research studies
  • Nurses are isolated from other colleagues knowledgeable in research
  • Nurses lack confidence to implement change
  • Lack of time for nurses to go to the library to read research
  • Inadequate library research holdings
  • Lack of organizational support for EBP when nurses wish to implement changes in patient care
• Fostering a culture of EBP at the undergraduate and graduate levels is one way in which health care educators attempt to make evidence-based care the gold standard of practice
• Facilitating support for EBP at the organizational level includes time to go to the library; teaching staff to conduct electronic searches; journal club meetings; establishing nursing research committees; linking staff with university researchers; and ensuring that adequate research journals and preprocessed evidence resources are available in the library
• Four types of patient data

  • Complete (Total Health) Database
  • Focused or Problem-Centered Database
  • Follow-Up Database
  • Emergency Database
• Complete (Total Health) Database


  Includes a complete health history and a full physical examination, describes the current and past health state and forms a baseline against which all future changes can be measured, yields the first diagnoses
• Focused or Problem-Centered Database


  For a limited or short-term problem, collects a "mini" database, smaller in scope and more targeted than the complete database, concerns mainly one problem, one cue complex, or one body system