Exam 1: Evidence-Based Assessment

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In many community settings, the nurse is the first and often the only health professional continually present at the bedside. It is becoming increasingly important for assessment skills to be practiced, with hands-on experience, and to be refined to a high level. Current cost-containment and budget-cutting efforts have led to a hospital population composed of people with illnesses of increased acuity, shorter stays, and earlier discharges than before. As a result, nurses must often go to people's homes for follow-up assessments. These situations require first-rate assessment skills that are based on a holistic approach and knowledge of age-specific problems.

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The nurse needs to determine quickly the level of priority of patient problems. First-level priority problems are immediate priorities that relate to the "ABCS"-airway problems, breathing problems, cardiac/circulatory problems, and signs (vital signs concerns). Second-level priority problems are immediate, but only after treatment for first-level problems is started. Examples of second-level priority problems include mental status change, acute pain, untreated medical problems, and abnormal laboratory values. Third-level priority problems are later priorities and include health problems related to lack of knowledge, activity, rest, and family coping.

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The practitioner must modify the approach to data collection on the basis of the presenting clinical situation. A health care provider in an emergency department will need to assess airway, breathing, and circulation and complete a problem-focused examination. An individual gathering data for a complete history and physical examination will usually examine each system in depth. Four different types of clinical situations and related data bases are identified: complete (or total health) data base, episodic or problem-centered data base, follow-up data base, and emergency data base. After identifying the type of data base indicated, the practitioner must proceed to gather the correct data. The data base will form the basis of one or more nursing diagnoses.