Exam 1 Study Guide
Chapter 1: Evidence-Based Assessment
ASSESSMENT- POINT OF ENTRY IN AN ONGOING PROCESS
● Assessment is the collection of data about the individual’s health (from patient, family
member, care-taker)
● Different elements form a database such as:
○ Subjective data: what they person says during history taking
○ Objective data: what you as the health professional observe by inspecting,
percussing, palpating, and auscultating during the physical exam
○ Patient’s record
○ Laboratory studies
● From the database you make a clinical judgement or diagnosis about the individual’s
health state, response to actual or potential health problems, and life processes
● The purpose of assessment is to make a judgement or diagnosis. An organized assessment
is the starting point of diagnostic reasoning
DIAGNOSTIC REASONING
● Diagnostic reasoning is the process of analyzing health data and drawing conclusions to
identify diagnoses
● Novice examiners may be able to effectively collect data, but then they may treat all data
the same
● By developing a consistent approach for collecting and analyzing data, nurses are able to
make more accurate diagnoses
● Accurate diagnosis is the outcome-arriving at the correct diagnosis
○ Organize data into cluster: group data points based on their similarities
■ Organizing data into clusters is slow at first, but experienced examiners
can recognize patterns more quickly as they recall results from previous
situations
○ Use a combination of:
■ Deductive reasoning: known diagnosis —- expected findings
■ Inductive reasoning: repeated findings —- likely diagnosis
● Based on signs and symptoms
■ Abductive reasoning: you have clues —- make your best guess
● Thinking to determine the best explanation with the information at
hand
● This hypothesis is based in incomplete data; therefore, you must
complete your assessment and move to deductive and inductive
reasoning
○ Validate data: When unsure ask experienced clinicians
■ Even with years of clinical experience, some signs always require
validation
, ■ Look for gaps in data collection and be sure to find the missing pieces,
because identifying missing information is an essential critical-thinking
skill
CLINICAL JUDGEMENT AND THE DIAGNOSTIC PROCESS
● The nursing process is a five-step process that includes:
○ Assessment
■ During this phase, you will gather the data from the medical record and
patient and complete an assessment
○ Diagnosis
■ Clinical findings are interpreted and clinical judgement is used to
determine a diagnosis
○ Planning
■ Formulate goals and outcomes in collaboration with the patient as you
complete the planning stage
○ Implementation
■ Take action
○ Evaluation
■ Based on the evaluation, you may need to reassess or change the original
plan
● The steps that you are going to take to get a diagnosis
● Clinical judgement allows you to make the best evidence-based decisions for patient care
and is an essential skill for nursing practice
● The Clinical Judgement Model was developed as a way of structuring nursing education
to enhance clinical judgement skills of novice practitioners
○ Novice: more textbook, by the book, follows the rules exactly
○ Competent: able to assess with more confidence in predictable situations
○ Proficient: sees the whole picture, has experience, anticipates changes before they
happen
○ Expert: intuitive, fast, and fluid
PRIORITY PROBLEMS LEVEL
● First-Level Priority
○ Those that are emergent, life threatening, and immediate, such as establishing an
airway or supporting breathing
● Second-Level Priority
○ Those that are next in urgency- those requiring your prompt intervention to
forestall further deterioration
● Third-Level Priority
○ Those that are important to the patient’s health but can be attended to after more
urgent health problems are addressed. Interventions to treat these problems are
long term, and the response to treatment is expected to take more time. These
, problems may require a collaborative effort between the patient and health care
professionals
● Once you have determined problems, you must identify expected outcomes and work
with the patient to facilitate outcomes. Remember, your outcomes need to be measurable
● The final steps to the nursing process include evaluation and planning, You must
continuously evaluate whether you are on the right track and correct any missteps or
misinterpretation of data
● Collaborative team for complex problems
○ Approach to treatment involves multiple disciplines
UNDERSTANDING EVIDENCE-BASED PRACTICE
● The conviction that all patients deserve to be treated with the most current and
best-practice techniques led to the development of evidence-based practice
● 1850s: Florence Nightingale used research evidence to improve patient outcomes in the
Crimean War.
● 1970s: The term “Evidence-based medicine” was introduced.
● 1970-1980: Focus on “research utilization” which is now
● termed Evidence-based practice (EBP)
○ ntegration of research evidence, clinical expertise, clinical knowledge, and patient
values and preferences
○ Clinical decision making = best evidence from literature review
○ Looking for gaps in the literature
○ Fostering a culture of EBP
● Ask, Search, Appraise, Apply, Evaluate
● The definition of EBP is multifaceted and reflects holistic practice. Once thought to be
primarily clinical, EBP now encompasses the integration of research evidence, clinical
expertise, clinical knowledge, and patient values and preferences
TYPES OF HEALTH DATABASES IN NURSING ASSESSMENT
● Complete database
○ Often collected in a primary care setting such as a pediatric or family practice
clinic, independent or group private practice, college health service, women’s
health care agency, visiting nurse agency, or community health agency
○ When you work in these settings, you are the first health professional to see the
patient and have primary responsibility for monitoring the person’s health care
○ For the well and ill people, the complete database must screen for pathology and
determine the easy people respond to that pathology or to any health problem
○ Full health history and physical exam
○ Describes current and past health status
○ Baseline for future care
● Focused or Problem-Centered Database
○ This is for a limited or short-term problem
, ○ Smaller in scope and more targeted than the complete database
○ It concerns mainly one problem, one cue complex, or one body system
● Follow-Up Database
○ The status of any identified problems should be evaluated at regular and
appropriate intervals
○ This type of database is used in all settings to follow up both short-term and
chronic health problems
○ Tracks progress of identifies problems
○ Evaluates treatments and medication
○ Done regularly
● Emergency Database
○ This is an urgent, rapid collection of crucial information and often is compiled
concurrently with lifesaving measures
○ Diagnosis must be swift and sure
COMPREHENSIVE HEALTH CARE
● Assessment data provide important information that allows you as a health care provider
to make appropriate plans and ensure quality care for the patient
● Holistic health views the mind, body, and spirit as interdependent and functioning as a
whole within the environment
○ Health depends on all factors working together
○ Talk to your patient to determine what they consider health and well-being
○ You must involve your patient throughout the process and work with them as you
plan interventions
○ While genetics play a role in health, the environment a person lives in has a more
significant impact
● Social Determinants of Health
○ Factors that influence a person’s health and well-being
○ These include
■ Environment
■ Access to health care
■ Community
■ Education
■ Economic stability
○ Some are not modifiable
○ You must recognize potential barriers to good health and work with the patient to
determine solutions
Chapter 2: Cultural Assessment
Part of forming trust with your patient is listening to each patient’s individual needs and
establishing an awareness of the person’s culture. You must be open to people who are different
Chapter 1: Evidence-Based Assessment
ASSESSMENT- POINT OF ENTRY IN AN ONGOING PROCESS
● Assessment is the collection of data about the individual’s health (from patient, family
member, care-taker)
● Different elements form a database such as:
○ Subjective data: what they person says during history taking
○ Objective data: what you as the health professional observe by inspecting,
percussing, palpating, and auscultating during the physical exam
○ Patient’s record
○ Laboratory studies
● From the database you make a clinical judgement or diagnosis about the individual’s
health state, response to actual or potential health problems, and life processes
● The purpose of assessment is to make a judgement or diagnosis. An organized assessment
is the starting point of diagnostic reasoning
DIAGNOSTIC REASONING
● Diagnostic reasoning is the process of analyzing health data and drawing conclusions to
identify diagnoses
● Novice examiners may be able to effectively collect data, but then they may treat all data
the same
● By developing a consistent approach for collecting and analyzing data, nurses are able to
make more accurate diagnoses
● Accurate diagnosis is the outcome-arriving at the correct diagnosis
○ Organize data into cluster: group data points based on their similarities
■ Organizing data into clusters is slow at first, but experienced examiners
can recognize patterns more quickly as they recall results from previous
situations
○ Use a combination of:
■ Deductive reasoning: known diagnosis —- expected findings
■ Inductive reasoning: repeated findings —- likely diagnosis
● Based on signs and symptoms
■ Abductive reasoning: you have clues —- make your best guess
● Thinking to determine the best explanation with the information at
hand
● This hypothesis is based in incomplete data; therefore, you must
complete your assessment and move to deductive and inductive
reasoning
○ Validate data: When unsure ask experienced clinicians
■ Even with years of clinical experience, some signs always require
validation
, ■ Look for gaps in data collection and be sure to find the missing pieces,
because identifying missing information is an essential critical-thinking
skill
CLINICAL JUDGEMENT AND THE DIAGNOSTIC PROCESS
● The nursing process is a five-step process that includes:
○ Assessment
■ During this phase, you will gather the data from the medical record and
patient and complete an assessment
○ Diagnosis
■ Clinical findings are interpreted and clinical judgement is used to
determine a diagnosis
○ Planning
■ Formulate goals and outcomes in collaboration with the patient as you
complete the planning stage
○ Implementation
■ Take action
○ Evaluation
■ Based on the evaluation, you may need to reassess or change the original
plan
● The steps that you are going to take to get a diagnosis
● Clinical judgement allows you to make the best evidence-based decisions for patient care
and is an essential skill for nursing practice
● The Clinical Judgement Model was developed as a way of structuring nursing education
to enhance clinical judgement skills of novice practitioners
○ Novice: more textbook, by the book, follows the rules exactly
○ Competent: able to assess with more confidence in predictable situations
○ Proficient: sees the whole picture, has experience, anticipates changes before they
happen
○ Expert: intuitive, fast, and fluid
PRIORITY PROBLEMS LEVEL
● First-Level Priority
○ Those that are emergent, life threatening, and immediate, such as establishing an
airway or supporting breathing
● Second-Level Priority
○ Those that are next in urgency- those requiring your prompt intervention to
forestall further deterioration
● Third-Level Priority
○ Those that are important to the patient’s health but can be attended to after more
urgent health problems are addressed. Interventions to treat these problems are
long term, and the response to treatment is expected to take more time. These
, problems may require a collaborative effort between the patient and health care
professionals
● Once you have determined problems, you must identify expected outcomes and work
with the patient to facilitate outcomes. Remember, your outcomes need to be measurable
● The final steps to the nursing process include evaluation and planning, You must
continuously evaluate whether you are on the right track and correct any missteps or
misinterpretation of data
● Collaborative team for complex problems
○ Approach to treatment involves multiple disciplines
UNDERSTANDING EVIDENCE-BASED PRACTICE
● The conviction that all patients deserve to be treated with the most current and
best-practice techniques led to the development of evidence-based practice
● 1850s: Florence Nightingale used research evidence to improve patient outcomes in the
Crimean War.
● 1970s: The term “Evidence-based medicine” was introduced.
● 1970-1980: Focus on “research utilization” which is now
● termed Evidence-based practice (EBP)
○ ntegration of research evidence, clinical expertise, clinical knowledge, and patient
values and preferences
○ Clinical decision making = best evidence from literature review
○ Looking for gaps in the literature
○ Fostering a culture of EBP
● Ask, Search, Appraise, Apply, Evaluate
● The definition of EBP is multifaceted and reflects holistic practice. Once thought to be
primarily clinical, EBP now encompasses the integration of research evidence, clinical
expertise, clinical knowledge, and patient values and preferences
TYPES OF HEALTH DATABASES IN NURSING ASSESSMENT
● Complete database
○ Often collected in a primary care setting such as a pediatric or family practice
clinic, independent or group private practice, college health service, women’s
health care agency, visiting nurse agency, or community health agency
○ When you work in these settings, you are the first health professional to see the
patient and have primary responsibility for monitoring the person’s health care
○ For the well and ill people, the complete database must screen for pathology and
determine the easy people respond to that pathology or to any health problem
○ Full health history and physical exam
○ Describes current and past health status
○ Baseline for future care
● Focused or Problem-Centered Database
○ This is for a limited or short-term problem
, ○ Smaller in scope and more targeted than the complete database
○ It concerns mainly one problem, one cue complex, or one body system
● Follow-Up Database
○ The status of any identified problems should be evaluated at regular and
appropriate intervals
○ This type of database is used in all settings to follow up both short-term and
chronic health problems
○ Tracks progress of identifies problems
○ Evaluates treatments and medication
○ Done regularly
● Emergency Database
○ This is an urgent, rapid collection of crucial information and often is compiled
concurrently with lifesaving measures
○ Diagnosis must be swift and sure
COMPREHENSIVE HEALTH CARE
● Assessment data provide important information that allows you as a health care provider
to make appropriate plans and ensure quality care for the patient
● Holistic health views the mind, body, and spirit as interdependent and functioning as a
whole within the environment
○ Health depends on all factors working together
○ Talk to your patient to determine what they consider health and well-being
○ You must involve your patient throughout the process and work with them as you
plan interventions
○ While genetics play a role in health, the environment a person lives in has a more
significant impact
● Social Determinants of Health
○ Factors that influence a person’s health and well-being
○ These include
■ Environment
■ Access to health care
■ Community
■ Education
■ Economic stability
○ Some are not modifiable
○ You must recognize potential barriers to good health and work with the patient to
determine solutions
Chapter 2: Cultural Assessment
Part of forming trust with your patient is listening to each patient’s individual needs and
establishing an awareness of the person’s culture. You must be open to people who are different
