Evidence-Based Assessment Lecture Notes

Objectives

• Understand assessment as a primary step in the nursing process for planning client and family-centered care.

Types of Data in Assessment

• Subjective Data: Information shared by the client or caregiver.
• Objective Data: Observations made by the nurse through:
  • Inspection
  • Percussion
  • Palpation
  • Auscultation

Types of Databases

• Complete Database:
  • Collected in a provider's office or clinic when no prior information is available.
  • Includes complete health history and a full head-to-toe physical assessment.
• Focused/Problem-Centered Database:
  • For limited or acute problems (e.g., fever and sore throat).
• Follow-Up Database:
  • Used across settings to assess improvement or changes in chronic conditions.
• Emergency Database:
  • Rapid data collection in life-threatening situations (e.g., allergic reactions, drug overdoses).
  • Followed by a thorough database once the client is stable.

Clinical Judgment and Diagnostic Reasoning

• Utilize critical thinking to analyze collected data and make evidence-based decisions.
• Critical Thinking Principles:
  • Sequential steps from novice to expert.
  • Multidimensional thinking approach.
  • Validate and confirm data findings.
  • Cluster data for evidence-based support and differential diagnosis.

Priority Problem Levels

• First Level Priority:
  • Emergent, life-threatening, requires immediate attention.
• Second Level Priority:
  • Urgent, preventing further deterioration.
• Third Level Priority:
  • Important, but can be addressed after more urgent issues.
• Collaborative Problems:
  • Involve multiple disciplines (e.g., therapy, nutrition).

Clinical Decision Making

• Randomized Clinical Trials (RCTs):
  • Basis for evidence-based practice since the 1970s.
  • Provide standards of care that improve client outcomes.

High-Level Assessment Skills

• Nurses as primary assessors and presence at the bedside.
• Importance of life cycle, holism, and culture in assessment.
• Learning from accessing more clients.

Assessment Through the Life Cycle

• Components:
  • Growth and development
  • Age-specific milestones
  • Immunizations
• Health promotion and disease prevention at all visits.

Frequency of Assessments

• Varies with illness and wellness needs.
• Routine periodic examinations for preventive care.
• Examples include dietary, physical activity, substance use, and sexual practices.

Routine Periodic Assessment

• Discussion on the need and frequency of checkups.
• Individualized based on risk factors and health needs.
• Timing of procedures may change (e.g., spacing out Pap tests).

For any questions, reach out to your course professor.