lOMoARcPSD|70468202
HEALTH ASSESSMENT: EXAM 1
Chapter 1: Evidence Based Assessment
Assessment- is the collection of data about an individual's state of health.
Evidence-based practice- it's a systematic approach to practice that uses: research evidence,
clinical expertise, clinical knowledge, and the client's values and preferences.
Decisions should not be made without good reason
That is why we need the data to make appropriate clinical decision
What Data do we Turn to?
Research- leads to positive patient outcomes
Search the literature on the subject matter for positive outcomes that occurred as a result of the
implementation.
Example: The spread of infection can be stopped by using PPE; hand washing, gloves, mask.
Clinical Experience
Clinical Knowledge
Client’s Preferences and Values
ADPIE
5 Systematic Steps That Occur in Order
Assessment- This step always comes first because you cannot proceed to the other steps until
you have the assessment information. Collecting data both subjective and objective, review
clinical record, health history, physical exam, functional assessment, and document relevant data.
Diagnosis- This is where the nurse determines what is going on. Compare clinical findings,
interpret data, make hypotheses, and derive a diagnosis.
Planning- This is where the nurse now knows what is going on but has to plan what to do about
it. Establish priorities, develop patient goals, establish realistic, measurable, outcomes.
Implementation- This is where the nurse puts her plan into action. Use evidence-based
interventions, coordinate care, use community resources, provide health teaching and health
promotions.
Evaluation- This is where the nurse determines if the interventions worked. Evaluate the
progress toward outcomes. Include patients in the evaluation process.
, lOMoARcPSD|70468202
Example of ADPIE in Action
Assessment- The nurse observes that the client is shaky and sweating. The nurse takes the
glucose level and determines that the glucose is low.
Diagnosis- As a result of the assessment findings, the nurse determines hypoglycemia is
occurring.
Planning- The nurse establishes her priority of increasing the glucose level first, and then
educating the client about glucose maintenance.
Implementation- The nurse gives the client some juice and crackers. When the client is stable
the nurse will provide education and resources to assist the client with glucose maintenance.
Evaluation- The nurse determines that after 15 minutes the glucose level increased as a result of
the implementation. The client was also able to verbalize that they must drink some juice and
crackers if this occurs to them while they are at home.
Appropriate Database for the Situation
Gathering objective and subjective data along with the client's record the nurse formulates a
database.
1. Complete- complete health history full physical exam current and past medical history this is
a Baseline. Perception of health and illness can be measured against. Will give the first
diagnosis. A primary care setting builds relationships with the client. In the hospital setting data
is gathered on admission. Can include elements such as detailed medical history, medications,
client’s perception of health, vaccine records as examples.
2. Problem centered Focus database- mini database focus on one main problem. Such as a
sore throat. Can occur in all settings.
3. Follow up database- examining what has occurred since the last visit. Has it gotten worse,
or has gotten better? Example: Follow-up from surgery.
4. Emergency database- rapid collection because of a life-threatening incident. Some examples
are heart attack, drug overdose, bleeding, concussion/ altered mental status.
, lOMoARcPSD|70468202
Subjective Data VS Objective Data
Subjective data-is what the patient states. It's not measurable. The nurse needs to validate it.
Example: Last bowel movement, pain measurement, nausea, vaccine record, patient states
falling.
Objective data- is what can be seen or measured it is what the nurse sees an objective
measurement that she takes/receives. Examples: Heart rate, wound measurement, blood pressure,
lab results, facial grimacing.
Diagnostic reasoning- the steps from data collection to the diagnosis can be a difficult one.
Diagnostic reasoning is the process of analyzing Health Data and drawing conclusions to identify
a diagnosis.
Components of diagnostic reasoning include:
Attending to initial available cues
Formulating diagnostic hypotheses
Gather/cluster data relevant to the hypotheses
Evaluating each hypothesis with the data collected
Cluster or group together assessment data that appears to be casual or associated.
Example: associated with a cold: runny nose, sore throat, and a cough. Something casual could
include a headache, it may be related, and it may not be related.
Critical thinking- is the thinking process needed for diagnostic reasoning; it's clinical
judgement relevant information should be identified, and clinical use gathered.
Now that we Have the Data, what do we do with it?
Hypothesize!
Organize the data
Cluster clues into groups, that just make sense
Evaluate the data
Diagnose
Prioritize
HEALTH ASSESSMENT: EXAM 1
Chapter 1: Evidence Based Assessment
Assessment- is the collection of data about an individual's state of health.
Evidence-based practice- it's a systematic approach to practice that uses: research evidence,
clinical expertise, clinical knowledge, and the client's values and preferences.
Decisions should not be made without good reason
That is why we need the data to make appropriate clinical decision
What Data do we Turn to?
Research- leads to positive patient outcomes
Search the literature on the subject matter for positive outcomes that occurred as a result of the
implementation.
Example: The spread of infection can be stopped by using PPE; hand washing, gloves, mask.
Clinical Experience
Clinical Knowledge
Client’s Preferences and Values
ADPIE
5 Systematic Steps That Occur in Order
Assessment- This step always comes first because you cannot proceed to the other steps until
you have the assessment information. Collecting data both subjective and objective, review
clinical record, health history, physical exam, functional assessment, and document relevant data.
Diagnosis- This is where the nurse determines what is going on. Compare clinical findings,
interpret data, make hypotheses, and derive a diagnosis.
Planning- This is where the nurse now knows what is going on but has to plan what to do about
it. Establish priorities, develop patient goals, establish realistic, measurable, outcomes.
Implementation- This is where the nurse puts her plan into action. Use evidence-based
interventions, coordinate care, use community resources, provide health teaching and health
promotions.
Evaluation- This is where the nurse determines if the interventions worked. Evaluate the
progress toward outcomes. Include patients in the evaluation process.
, lOMoARcPSD|70468202
Example of ADPIE in Action
Assessment- The nurse observes that the client is shaky and sweating. The nurse takes the
glucose level and determines that the glucose is low.
Diagnosis- As a result of the assessment findings, the nurse determines hypoglycemia is
occurring.
Planning- The nurse establishes her priority of increasing the glucose level first, and then
educating the client about glucose maintenance.
Implementation- The nurse gives the client some juice and crackers. When the client is stable
the nurse will provide education and resources to assist the client with glucose maintenance.
Evaluation- The nurse determines that after 15 minutes the glucose level increased as a result of
the implementation. The client was also able to verbalize that they must drink some juice and
crackers if this occurs to them while they are at home.
Appropriate Database for the Situation
Gathering objective and subjective data along with the client's record the nurse formulates a
database.
1. Complete- complete health history full physical exam current and past medical history this is
a Baseline. Perception of health and illness can be measured against. Will give the first
diagnosis. A primary care setting builds relationships with the client. In the hospital setting data
is gathered on admission. Can include elements such as detailed medical history, medications,
client’s perception of health, vaccine records as examples.
2. Problem centered Focus database- mini database focus on one main problem. Such as a
sore throat. Can occur in all settings.
3. Follow up database- examining what has occurred since the last visit. Has it gotten worse,
or has gotten better? Example: Follow-up from surgery.
4. Emergency database- rapid collection because of a life-threatening incident. Some examples
are heart attack, drug overdose, bleeding, concussion/ altered mental status.
, lOMoARcPSD|70468202
Subjective Data VS Objective Data
Subjective data-is what the patient states. It's not measurable. The nurse needs to validate it.
Example: Last bowel movement, pain measurement, nausea, vaccine record, patient states
falling.
Objective data- is what can be seen or measured it is what the nurse sees an objective
measurement that she takes/receives. Examples: Heart rate, wound measurement, blood pressure,
lab results, facial grimacing.
Diagnostic reasoning- the steps from data collection to the diagnosis can be a difficult one.
Diagnostic reasoning is the process of analyzing Health Data and drawing conclusions to identify
a diagnosis.
Components of diagnostic reasoning include:
Attending to initial available cues
Formulating diagnostic hypotheses
Gather/cluster data relevant to the hypotheses
Evaluating each hypothesis with the data collected
Cluster or group together assessment data that appears to be casual or associated.
Example: associated with a cold: runny nose, sore throat, and a cough. Something casual could
include a headache, it may be related, and it may not be related.
Critical thinking- is the thinking process needed for diagnostic reasoning; it's clinical
judgement relevant information should be identified, and clinical use gathered.
Now that we Have the Data, what do we do with it?
Hypothesize!
Organize the data
Cluster clues into groups, that just make sense
Evaluate the data
Diagnose
Prioritize
