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    Critical Thinking in Health Assessment

    Uploaded by

    Livan Martell

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    © All Rights Reserved
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    Critical Thinking in Health Assessment

    Uploaded by

    Livan Martell
    37 views27 pages

    Original Title

    Chapter 2

    Copyright

    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    37 views27 pages

    Critical Thinking in Health Assessment

    Uploaded by

    Livan Martell

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 27
    At a glance
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    The key takeaways are that the document discusses the nursing process, types of patient data, examples of patient data, open-ended vs closed-ended questions, and challenges of clinical data.

    The steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation (ADPIE).

    The two main types of patient data are subjective - what the patient reports, and objective - what is observed.

    Chapter 2

    Critical Thinking in Health


    Assessment

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    The Nursing Process
     Set a goal
     Develop an action plan
     Implement the plan
     Evaluate the outcome

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Types of Patient Data
     Subjective—Symptoms  Objective—Signs
    o What patient tells you o What you see
    o History o Physical examination
    o Chief o Laboratory reports
    complaint(always o Radiologic findings
    written in the
    patient own words)
    o Review of systems

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Examples of Patient Data
     Mrs. G is a 54-year-old  Mrs. G is an older,
    hairdresser who overweight white
    reports pressure over female, who is
    her left chest “like an pleasant and
    elephant sitting there” cooperative. Height
    which radiates to her 5’4”, weight 150 lb.
    left neck and arm. BMI 26, BP 160/80
    right arm, sitting, HR
    96 and regular,
    respiratory rate 24 and
    regular, temperature
    97.5˚F oral.

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Open Ended questions vs Closed Ended Questions

     Open-ended questions are questions that cannot be answered with a


    simple 'yes' or 'no', and instead require the respondent to elaborate on their
    points.
     Can you describe me your headache from when it began until now?
     What brough you to the clinic today?
     What do you think it means to be healthy?
    Close –ended questions are questions that can be answered with a yes or no.
     Do you have a headache?
     Do you have leg burning pain?
     Are you Healthy?

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Nursing Process #1
     Broad systematic framework
     Provides methodical base
     Problem-solving approach addresses human response,
    needs of patient, family, and community

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Nursing Process #2
     ADPIE
    o Assessment
    o Diagnosis
    o Planning
    o Implementation
    o Evaluation

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Assessment
     Gathering subjective and objective data
     Instrumental in devising a care plan
     Key points and relevant pieces of information are
    clustered together
     Preliminary problem list is formulated
     Assessment phase continues throughout entire patient
    encounter

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Diagnosis
     Based on real or potential health problems or human
    responses to health problems
     Based on assessment data and patient problem list
     Sets stage for remainder of care plan

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Planning
     Devise the best course of action to address patient’s
    diagnoses
     Nurse and patient select goals for each diagnosis
     Set short-term goals (STG) and long-term goals (LTG)
     Be realistic
     Work with patient’s goals, economic means, competing
    responsibilities, and family structure and dynamics

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Implementation
     Can be completed by patient, family, or health care
    team
     Clearly relate to nursing diagnosis and planned goals
     Individualized for each patient
     Modified as changes occur
     Support positive outcomes

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Evaluation
     Continuing process to determine if goals have been
    attained
     Based on patient’s condition
     Goals are realistic or appropriate
     Ongoing process
     Confirms that nursing care is relevant

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Question #1
     The nursing process has several steps. These include
    which components? (Select all that apply)
    A. Evaluation
    B. Assessment
    C. Diagnosis
    D. Family approval
    E. Planning

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Answer to Question #1
     The nursing process has several steps. These include
    which components? (Select all that apply)
    A. Evaluation
    B. Assessment
    C. Diagnosis
    E. Planning
     The nursing process has five steps: assessment,
    diagnosis, planning, implementation, and evaluation.
    Including the family is important, but not one of our
    steps.

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Assessment and Diagnosis:
    The Process of Clinical Reasoning
     Three types of reasoning for clinical problem solving:
    o Pattern recognition
    o Development of schemas
    o Application of relevant basic and clinical science

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Steps in Clinical Reasoning
     Identify abnormal or positive findings
     Cluster the findings
     Interpret/Review the findings
     Make hypotheses about the nature of the patient’s
    problem
     Test the hypotheses and establish a working nursing
    diagnosis
     Develop a plan agreeable to the patient

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Identify Abnormal or Positive Findings
     Make a list
    o Patient’s symptoms
    o Observed signs
     Identify the positive responses

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Cluster the Findings
     Group complaints with area in body
     Include information on stress level
     Be specific
     Localize symptoms and signs, if possible
     Include any psychosocial issues

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Interpret the Findings
     Patient problems can stem from different causes:
    o Disease processes
    o Relationships
    o Nutritional
    o Immunologic
    o Infectious
    o Congenital
    o Many more

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Make Hypotheses
     Nature of the patient’s problem
     Continue learning about patterns of abnormal diseases
    and issues
     Consult clinical literature
     Evidence-based decision making
     As broader knowledge and experience are gained, you
    will begin to develop highly specific hypotheses

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Nursing Diagnoses
     Based primarily on:
    o Changes in person’s life
    o Altered processes
    o Specific causes
     Complaints may not fall neatly into these categories
     May be related to stressful events

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Health Maintenance
     Immunizations (always part of the past medical
    history)
     Screening measures
     Nutrition instruction
     Self-screening examinations
     Exercise
     Seat belt use
     Responding to important life events

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Develop a Plan
     Must be agreeable to patient
     Develop and record plan for each problem
     Specify what steps are needed
     Share assessment with patient
     Ask the patient for his or her opinion
     Patient should always be an active participant of plan
     Adapt and change as problems change

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    Generating Problem List
     List the most active and serious problem first and record
    date of onset
     No specific method
    o Order of priority
    o Separate lists for active and inactive problems
    o Assign each problem a number to be referenced in
    health record
     Use list to check status of problems in future visits
     Allows other health care team members to review
    patient status

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    The Challenges of Clinical Data #1
     Cluster data into single versus multiple problems
    o Age
    o Timing
    o Different body systems
    o Multisystem conditions

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    The Challenges of Clinical Data #2
     Sifting through an extensive array of data
    o Pull out separate clusters of observations and analyze
    one cluster at a time
    o Ask a series of key questions to guide in a specific
    direction

    Copyright © 2018 Wolters Kluwer · All Rights Reserved


    The Challenges of Clinical Data #3
     Assessing the quality of the data
    o Subject to error
    o Ask open-ended questions
    o Listen carefully
    o Follow “yes” answers with “OLD CART”
    o Keep an open mind
    o Always include worse-case scenario
    o Confer with colleagues to clarify uncertainties

    Copyright © 2018 Wolters Kluwer · All Rights Reserved

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