Chapter 1 – Evidence-Based Assessment
Assessment – Point of Entry in an Ongoing Process
Assessment is the collection of data about an individual’s health state
Subjective Data – what the person says
Objective Data - what you see/observe by inspecting, percussing, palpating, and auscultating during
physical examination
Together, with patients records and lab studies, these elements form the database
From the database, you make a clinical judgment on diagnosis about pts health state, response
to actual/potential health problems, and life processes
So, the purpose of assessment is to make a judgement or diagnosis
An organized assessment is the starting point of diagnostic reasoning (as all health care
diagnoses, decisions, and treatments are based on the data you collect)
Patient’s record and laboratory studies within the electronic heath record (HER)
EBP is integration of research evidence, clinical expertise, clinical knowledge, pt values/preferences
Information from EHR allows nurses to make clinical judgement or diagnosis about patient’s health
state
Key is organization of assessment based on complete factually based data
Diagnostic Reasoning
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify
diagnoses
Hypothetico-deductive process (usually used by novice examiners)
Attending to initially available cues (pieces of information)
, Formulating diagnostic hypotheses (tentative explanation of cues).
▪ Gathering data relative to the tentative hypothesis
Evaluating each hypothesis with the new data collected
Thus, arriving at final diagnosis serve as basis for ongoing investigation.
Initially available cues – is a piece of information, a sign or symptom, or a piece of laboratory/imaging
data
Hypothesis - uncertain explanation for a cue, or set of cues that can be used as a basis for further
investigation
Cluster/group together assessment data that appear to be casual or associated.
Gathering/recording relevant data
Evaluate each hypothesis with ongoing data collection
Validate the data you collect to ensure they are accurate
Look for gaps and ensure you find the missing pieces – identifying missing information is an essential
critical-thinking skill
Serves as a basis for ongoing investigation, ongoing assessment
Four Factors for Clinical Decision Making
- Literature review
- Patient preferences
- Clinical experience/expertise
- Physical exam and assessment
, Critical Thinking and the Diagnostic Process
Nursing process
Includes six phases
Assessment
• Collect data:
• Review of the clinical record
• Health history
• Physical examination
• Functional assessment
• Risk assessment
• Review of the literature
Use evidence-based assessment techniques
Document relevant data
Diagnosis
▪ Compare clinical findings with normal and abnormal variation and developmental events
▪ Interpret data
▪ Identify clusters and cues
▪ Make hypotheses
▪ Test hypotheses
, ▪ Derive/develop diagnoses
▪ Validate diagnoses
▪ Document diagnoses
Outcome identification
▪ Identify expected outcomes
▪ Individualize to the person
▪ Identify expected culturally appropriate outcomes
▪ Establish realistic and measurable outcomes/goals (have dangling feet by certain time)
▪ Develop a timeline
Planning
▪ Establish priorities
▪ Develop outcomes
▪ Set timelines for outcomes
▪ Identify interventions
▪ Integrate evidence-based trends and research
▪ Document plan of care
▪ Encourage pts to talk about themselves
▪ ABCs priority
Implementation
▪ Implement in a safe and timely manner
Assessment – Point of Entry in an Ongoing Process
Assessment is the collection of data about an individual’s health state
Subjective Data – what the person says
Objective Data - what you see/observe by inspecting, percussing, palpating, and auscultating during
physical examination
Together, with patients records and lab studies, these elements form the database
From the database, you make a clinical judgment on diagnosis about pts health state, response
to actual/potential health problems, and life processes
So, the purpose of assessment is to make a judgement or diagnosis
An organized assessment is the starting point of diagnostic reasoning (as all health care
diagnoses, decisions, and treatments are based on the data you collect)
Patient’s record and laboratory studies within the electronic heath record (HER)
EBP is integration of research evidence, clinical expertise, clinical knowledge, pt values/preferences
Information from EHR allows nurses to make clinical judgement or diagnosis about patient’s health
state
Key is organization of assessment based on complete factually based data
Diagnostic Reasoning
Diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify
diagnoses
Hypothetico-deductive process (usually used by novice examiners)
Attending to initially available cues (pieces of information)
, Formulating diagnostic hypotheses (tentative explanation of cues).
▪ Gathering data relative to the tentative hypothesis
Evaluating each hypothesis with the new data collected
Thus, arriving at final diagnosis serve as basis for ongoing investigation.
Initially available cues – is a piece of information, a sign or symptom, or a piece of laboratory/imaging
data
Hypothesis - uncertain explanation for a cue, or set of cues that can be used as a basis for further
investigation
Cluster/group together assessment data that appear to be casual or associated.
Gathering/recording relevant data
Evaluate each hypothesis with ongoing data collection
Validate the data you collect to ensure they are accurate
Look for gaps and ensure you find the missing pieces – identifying missing information is an essential
critical-thinking skill
Serves as a basis for ongoing investigation, ongoing assessment
Four Factors for Clinical Decision Making
- Literature review
- Patient preferences
- Clinical experience/expertise
- Physical exam and assessment
, Critical Thinking and the Diagnostic Process
Nursing process
Includes six phases
Assessment
• Collect data:
• Review of the clinical record
• Health history
• Physical examination
• Functional assessment
• Risk assessment
• Review of the literature
Use evidence-based assessment techniques
Document relevant data
Diagnosis
▪ Compare clinical findings with normal and abnormal variation and developmental events
▪ Interpret data
▪ Identify clusters and cues
▪ Make hypotheses
▪ Test hypotheses
, ▪ Derive/develop diagnoses
▪ Validate diagnoses
▪ Document diagnoses
Outcome identification
▪ Identify expected outcomes
▪ Individualize to the person
▪ Identify expected culturally appropriate outcomes
▪ Establish realistic and measurable outcomes/goals (have dangling feet by certain time)
▪ Develop a timeline
Planning
▪ Establish priorities
▪ Develop outcomes
▪ Set timelines for outcomes
▪ Identify interventions
▪ Integrate evidence-based trends and research
▪ Document plan of care
▪ Encourage pts to talk about themselves
▪ ABCs priority
Implementation
▪ Implement in a safe and timely manner
