Chapter 1

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Evidence-Based AssessmentEvidence-Based Assessment
Chapter 1Chapter 1

Chapter 1: Evidence-Based AssessmentChapter 1: Evidence-Based Assessment
Slide 1-2
Assessment:Assessment:
Point of Entry in an Ongoing ProcessPoint of Entry in an Ongoing Process
 Subjective dataSubjective data
 What patient says about himself or herself duringWhat patient says about himself or herself during
history takinghistory taking
 Objective dataObjective data
 Observed when inspecting, percussing, palpating,Observed when inspecting, percussing, palpating,
and auscultating patient during physicaland auscultating patient during physical
examinationexamination
 Data baseData base
 Formed from these elements, plus patient’s recordFormed from these elements, plus patient’s record
and laboratory studiesand laboratory studies

Slide 1-3
Clinical Reasoning ModelsClinical Reasoning Models
 Diagnostic reasoningDiagnostic reasoning
 Nursing processNursing process
 Critical thinkingCritical thinking

Slide 1-4
Diagnostic ReasoningDiagnostic Reasoning
 Attend to initially available cuesAttend to initially available cues
 CueCue: piece of information, sign, symptom, or piece: piece of information, sign, symptom, or piece
of laboratory dataof laboratory data
 Formulate diagnostic hypothesesFormulate diagnostic hypotheses
 HypothesisHypothesis: tentative explanation for cues used as: tentative explanation for cues used as
a basis for further investigationa basis for further investigation
 Gather data relative to tentative hypothesesGather data relative to tentative hypotheses
 Evaluate each hypothesis with new dataEvaluate each hypothesis with new data
collected to arrive at final diagnosiscollected to arrive at final diagnosis

Slide 1-5
Nursing ProcessNursing Process
 AssessmentAssessment
 DiagnosisDiagnosis
 Outcome identificationOutcome identification
 PlanningPlanning
 ImplementationImplementation
 EvaluationEvaluation

Slide 1-6
Nursing Process: AssessmentNursing Process: Assessment
 Collect dataCollect data
 Review of clinical recordReview of clinical record
 InterviewInterview
 Health historyHealth history
 Physical examinationPhysical examination
 Functional assessmentFunctional assessment
 Cultural and spiritual assessmentCultural and spiritual assessment
 ConsultationConsultation
 Review of the literatureReview of the literature

Slide 1-7
Nursing Process: DiagnosisNursing Process: Diagnosis
 Interpret dataInterpret data
 Identify clusters of cuesIdentify clusters of cues
 Make inferencesMake inferences
 Validate inferencesValidate inferences
 Compare clusters of cues with definitions andCompare clusters of cues with definitions and
defining characteristicsdefining characteristics
 Identify related factorsIdentify related factors
 Document the diagnosisDocument the diagnosis

Slide 1-8
Nursing Process:Nursing Process:
Outcome IdentificationOutcome Identification
 Identify expected outcomesIdentify expected outcomes
 Individualize to patientIndividualize to patient
 Ensure outcomes are realistic andEnsure outcomes are realistic and
measurablemeasurable
 Include a time frameInclude a time frame

Slide 1-9
Nursing Process: PlanningNursing Process: Planning
 Establish prioritiesEstablish priorities
 Develop outcomesDevelop outcomes
 Set time frames for outcomesSet time frames for outcomes
 Identify interventionsIdentify interventions
 Document plan of careDocument plan of care

Slide 1-10
Nursing Process: ImplementationNursing Process: Implementation
 Determine patient readinessDetermine patient readiness
 Review planned interventionsReview planned interventions
 Collaborate with other team membersCollaborate with other team members
 Supervise by delegating appropriateSupervise by delegating appropriate
responsibilitiesresponsibilities
 Counsel person and significant othersCounsel person and significant others
 Involve person in health careInvolve person in health care
 Refer for continuing careRefer for continuing care
 Document care providedDocument care provided

Slide 1-11
Nursing Process: EvaluationNursing Process: Evaluation
 Refer to established outcomesRefer to established outcomes
 Evaluate individual’s condition and compareEvaluate individual’s condition and compare
actual outcomes with expected outcomesactual outcomes with expected outcomes
 Summarize results of evaluationSummarize results of evaluation
 Identify reasons for failure to achieveIdentify reasons for failure to achieve
expected outcomesexpected outcomes
 Take corrective action to modify plan of careTake corrective action to modify plan of care
 Document evaluation in plan of careDocument evaluation in plan of care

Slide 1-12
Critical ThinkingCritical Thinking
 Identifying AssumptionsIdentifying Assumptions
 Recognize information taken for granted or factRecognize information taken for granted or fact
without evidence for itwithout evidence for it
 Organized approachOrganized approach
 Use an organized, systematic assessment formatUse an organized, systematic assessment format
 ValidationValidation
 Check and corroborate accuracy and reliability ofCheck and corroborate accuracy and reliability of
datadata
 Normal and abnormalNormal and abnormal
 DistinguishDistinguish when identifying signs and symptomswhen identifying signs and symptoms

Slide 1-13
Critical Thinking (cont.)Critical Thinking (cont.)
 Inferences or drawing valid conclusionsInferences or drawing valid conclusions
 Interpreting data and deriving correct conclusionsInterpreting data and deriving correct conclusions
 Clustering related cuesClustering related cues
 Assists seeing relationships among dataAssists seeing relationships among data
 RelevanceRelevance
 Look at clusters of data and consider which areLook at clusters of data and consider which are
important for health problemimportant for health problem
 InconsistenciesInconsistencies
 Recognize subjective data at odds with objectiveRecognize subjective data at odds with objective
datadata

Slide 1-14
 Identify patternsIdentify patterns
 Helps to see whole picture and discover missingHelps to see whole picture and discover missing
pieces of informationpieces of information
 Missing informationMissing information
 Identify gaps in data or need for more specificIdentify gaps in data or need for more specific
interviewing or laboratory data to make diagnosisinterviewing or laboratory data to make diagnosis
 Health promotionHealth promotion
 Identify and manage known risk factors forIdentify and manage known risk factors for
individual’s age group and cultural statusindividual’s age group and cultural status

Slide 1-15
 Risk diagnosisRisk diagnosis
 Identify actual and potential risks from full list ofIdentify actual and potential risks from full list of
both medical and nursing assessment databoth medical and nursing assessment data
 Set prioritiesSet priorities
 When there is more than one diagnosis:When there is more than one diagnosis:
• First-level priority problems: emergent, life threatening,First-level priority problems: emergent, life threatening,
and immediateand immediate
• Second-level priority problems: next in urgencySecond-level priority problems: next in urgency
• Third-level priority problems: important to patient’s healthThird-level priority problems: important to patient’s health
but can be addressed after more urgent problems arebut can be addressed after more urgent problems are
addressedaddressed

Slide 1-16
 Collaborative problemsCollaborative problems
 When approach to treatment involves multipleWhen approach to treatment involves multiple
disciplinesdisciplines
 OutcomesOutcomes
 DetermineDetermine patient-centered expected outcomespatient-centered expected outcomes
• Specific, measurable, results expected to improveSpecific, measurable, results expected to improve
person’s problem after treatmentperson’s problem after treatment
• Outcome statements include specific time frameOutcome statements include specific time frame

Slide 1-17
 InterventionsInterventions
 DetermineDetermine specific interventionsspecific interventions that will achievethat will achieve
expected outcomesexpected outcomes
• Interventions aim to prevent, manage, or resolve healthInterventions aim to prevent, manage, or resolve health
problemsproblems
• This is the health care planThis is the health care plan
 Evaluation and corrective thinkingEvaluation and corrective thinking
 Analyze outcomes and apply them for evaluationAnalyze outcomes and apply them for evaluation
• Do stated outcomes match individual’s actual progress?Do stated outcomes match individual’s actual progress?
• Continually think, “what could be done differently orContinually think, “what could be done differently or
better?”better?”

Slide 1-18
 Comprehensive plan of careComprehensive plan of care
 Evaluate and update planEvaluate and update plan
 Record revised plan and keep it up-to-dateRecord revised plan and keep it up-to-date
 Communicate revised plans to multidisciplinaryCommunicate revised plans to multidisciplinary
teamteam
 Be aware this is a legal document, and accurateBe aware this is a legal document, and accurate
recording is important for evaluation, insurancerecording is important for evaluation, insurance
reimbursement, and researchreimbursement, and research

Slide 1-19
USING A CONCEPTUALUSING A CONCEPTUAL
FRAMEWORK AS A GUIDEFRAMEWORK AS A GUIDE
 Data base: organization of assessment dataData base: organization of assessment data
varies depending on conceptual model usedvaries depending on conceptual model used
 Models provide a framework for:Models provide a framework for:
• Determining what to observeDetermining what to observe
• Organizing observations or dataOrganizing observations or data
• Interpreting and using the informationInterpreting and using the information
 Nursing diagnoses are clinical judgmentsNursing diagnoses are clinical judgments
about a person’s response to an actual orabout a person’s response to an actual or
potential health statepotential health state

Slide 1-20
EXPANDING THE CONCEPT OFEXPANDING THE CONCEPT OF
HEALTHHEALTH
 Assessment: collection of data about anAssessment: collection of data about an
individual’s health stateindividual’s health state
 A clear idea of health is important because itA clear idea of health is important because it
determines assessment data to be collecteddetermines assessment data to be collected

Slide 1-21
EXPANDING THE CONCEPT OFEXPANDING THE CONCEPT OF
HEALTH (cont.)HEALTH (cont.)
 Biomedical modelBiomedical model
 Health as absence of diseaseHealth as absence of disease
 Health and disease are opposite extremes onHealth and disease are opposite extremes on
linear continuumlinear continuum
 Disease is caused by specific agents or pathogensDisease is caused by specific agents or pathogens
 A natural progression to health promotion andA natural progression to health promotion and
disease prevention rounds out our concept ofdisease prevention rounds out our concept of
healthhealth
 Guidelines to prevention emphasize link betweenGuidelines to prevention emphasize link between
health and personal behaviorhealth and personal behavior

Slide 1-22
Collecting Four Types of DataCollecting Four Types of Data
 Complete total health data baseComplete total health data base
 Includes complete health history and full physicalIncludes complete health history and full physical
examinationexamination
 Describes current and past health state and formsDescribes current and past health state and forms
baseline to measure all future changesbaseline to measure all future changes
 Yields first diagnosesYields first diagnoses

Slide 1-23
Collecting Four TypesCollecting Four Types
of Data (cont.)of Data (cont.)
 Episodic or problem-centered data baseEpisodic or problem-centered data base
 For limited or short-term problemsFor limited or short-term problems
 Collect “mini” data base, smaller scope and moreCollect “mini” data base, smaller scope and more
focused than complete data basefocused than complete data base
 Concerns mainly one problem, one cue complex,Concerns mainly one problem, one cue complex,
or one body systemor one body system
 History and examination follow direction ofHistory and examination follow direction of
presenting concernpresenting concern
• Acute or chronic onset, associated with fever, local orAcute or chronic onset, associated with fever, local or
generalizedgeneralized

Slide 1-24
 Follow-up data baseFollow-up data base
 Status of all identified problems should beStatus of all identified problems should be
evaluated at regular and appropriate intervalsevaluated at regular and appropriate intervals
 Note changes that have occurredNote changes that have occurred
 Evaluate whether problem is getting better orEvaluate whether problem is getting better or
worseworse
 Identify coping strategies being usedIdentify coping strategies being used

Slide 1-25
 Emergency data baseEmergency data base
 Rapid collection of data, often compiledRapid collection of data, often compiled
concurrently with lifesaving measuresconcurrently with lifesaving measures
 Diagnosis must be swift and sureDiagnosis must be swift and sure
• Person is questioned simultaneously while his or herPerson is questioned simultaneously while his or her
airway, breathing, circulation, level of consciousness,airway, breathing, circulation, level of consciousness,
and disability are being assessedand disability are being assessed

Slide 1-26
FREQUENCY OF ASSESSMENTFREQUENCY OF ASSESSMENT
 Interval of assessment varies with illness andInterval of assessment varies with illness and
wellness needswellness needs
 Ill people seek care because of pain or abnormalIll people seek care because of pain or abnormal
signs and symptomssigns and symptoms
 This prompts an assessment: gathering complete,This prompts an assessment: gathering complete,
episodic, or emergency data baseepisodic, or emergency data base
• Screening history for dietary intake, physical activity,Screening history for dietary intake, physical activity,
tobacco/alcohol/drug use, and sexual practicestobacco/alcohol/drug use, and sexual practices
• Counseling for injury prevention, substance use, sexualCounseling for injury prevention, substance use, sexual
behavior, diet and exercise, and dental healthbehavior, diet and exercise, and dental health

Slide 1-27
FREQUENCY OFFREQUENCY OF
ASSESSMENT (cont.)ASSESSMENT (cont.)
 Routine periodic examination might includeRoutine periodic examination might include
following services for preventive health care:following services for preventive health care:
 Screening history for dietary intake, physicalScreening history for dietary intake, physical
activity, tobacco/alcohol/drug use, and sexualactivity, tobacco/alcohol/drug use, and sexual
practicespractices
 Counseling for injury prevention, substance use,Counseling for injury prevention, substance use,
sexual behavior, diet and exercise, and dentalsexual behavior, diet and exercise, and dental
healthhealth
 ImmunizationsImmunizations
 Chemoprophylaxis for multivitamin with folic acidChemoprophylaxis for multivitamin with folic acid
for females capable of or planning pregnancyfor females capable of or planning pregnancy

Slide 1-28
FREQUENCY OFFREQUENCY OF
ASSESSMENT (cont.)ASSESSMENT (cont.)
 For well persons, opinions are changingFor well persons, opinions are changing
about assessment intervalsabout assessment intervals
 Annual checkup is vague: What does it constitute?Annual checkup is vague: What does it constitute?
Is it necessary? Does it sometimes give an implicitIs it necessary? Does it sometimes give an implicit
promise of health and thus provide false security?promise of health and thus provide false security?
 Timing of formerly accepted procedures is nowTiming of formerly accepted procedures is now
variable: for example, annual Papanicolaou testsvariable: for example, annual Papanicolaou tests
 Same annual routine physical examination cannotSame annual routine physical examination cannot
be recommended for all persons because healthbe recommended for all persons because health
priorities vary among individuals, age groups, andpriorities vary among individuals, age groups, and
risk categoriesrisk categories

Slide 1-29
ASSESSMENT THROUGHASSESSMENT THROUGH
THE LIFE CYCLETHE LIFE CYCLE
 Age-specific charts for periodic healthAge-specific charts for periodic health
examinations are a positive approach toexaminations are a positive approach to
health assessmenthealth assessment
 Define lifetime schedule of health care, organizedDefine lifetime schedule of health care, organized
into packages for four specific age-groupsinto packages for four specific age-groups
 Each chart lists a frequency schedule for periodicEach chart lists a frequency schedule for periodic
health visits and preventive services for age grouphealth visits and preventive services for age group
• These services include screening factors to gatherThese services include screening factors to gather
during the history, and age-specific items for physicalduring the history, and age-specific items for physical
examination and laboratory procedures, counselingexamination and laboratory procedures, counseling
topics, and immunizationstopics, and immunizations

Slide 1-30
ASSESSMENT THROUGHASSESSMENT THROUGH
THE LIFECYCLE (cont.)THE LIFECYCLE (cont.)
 Age-specific charts focus on major riskAge-specific charts focus on major risk
factors specific for each age group based onfactors specific for each age group based on
lifestyle, health needs, and problemslifestyle, health needs, and problems
 Shift emphasis from an annual physicalShift emphasis from an annual physical
examination toward rational and varying periodicityexamination toward rational and varying periodicity
 Incorporate health promotion and diseaseIncorporate health promotion and disease
prevention at every health visit, not just at oneprevention at every health visit, not just at one
annual physical examinationannual physical examination
 Health education and counseling are highlightedHealth education and counseling are highlighted
as means to deliver health promotionas means to deliver health promotion

Slide 1-31
CROSS-CULTURAL CARECROSS-CULTURAL CARE
 A holistic model of health care assessmentA holistic model of health care assessment
must include culturemust include culture
 Inclusion of heritage assessment is ofInclusion of heritage assessment is of
paramount importance to gather meaningfulparamount importance to gather meaningful
data and intervene with culturally sensitivedata and intervene with culturally sensitive
and appropriate careand appropriate care
 With the rapid increases in numbers of individualsWith the rapid increases in numbers of individuals
from diverse cultural backgrounds in the U.S., afrom diverse cultural backgrounds in the U.S., a
concern for cultural beliefs and practices of peopleconcern for cultural beliefs and practices of people
is increasingly important in health careis increasingly important in health care

Slide 1-32
CROSS-CULTURALCROSS-CULTURAL
CARE (cont.)CARE (cont.)
 A serious conceptual problem arises asA serious conceptual problem arises as
nurses and physicians are expected to know,nurses and physicians are expected to know,
understand, and meet health needs of peopleunderstand, and meet health needs of people
from culturally diverse backgrounds withoutfrom culturally diverse backgrounds without
formal preparation for doing soformal preparation for doing so
 International interchanges are increasingInternational interchanges are increasing
among nurses and physicians, makingamong nurses and physicians, making
attention to cultural aspects of health andattention to cultural aspects of health and
illness an even greater priorityillness an even greater priority

Slide 1-33
HIGH-LEVELHIGH-LEVEL
ASSESSMENT SKILLSASSESSMENT SKILLS
 Attention to life cycle, holism, and cultureAttention to life cycle, holism, and culture
must not detract from importance ofmust not detract from importance of
assessment skills themselvesassessment skills themselves
 Assessment skills require hands-on expertiseAssessment skills require hands-on expertise
refined to a high levelrefined to a high level
 Nurse is first and often only health professional toNurse is first and often only health professional to
see an individual in many communitiessee an individual in many communities
 Nurse is only health professional continuallyNurse is only health professional continually
present at bedside in hospitalspresent at bedside in hospitals

Slide 1-34
HIGH-LEVELHIGH-LEVEL
ASSESSMENT SKILLS (cont.)ASSESSMENT SKILLS (cont.)
 Efforts at cost containment result in hospitalEfforts at cost containment result in hospital
populations composed of people withpopulations composed of people with
increased acuity, shorter stays, and earlierincreased acuity, shorter stays, and earlier
discharges than in pastdischarges than in past
 Nurses must make faster, more efficientNurses must make faster, more efficient
assessmentsassessments
 Nurses required go to people’s homes for follow-Nurses required go to people’s homes for follow-
up assessment and diagnosisup assessment and diagnosis
 First-rate assessment skills grounded in holisticFirst-rate assessment skills grounded in holistic
approach and knowledge of age-specific problemsapproach and knowledge of age-specific problems
are requiredare required

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