Deck 1: Evidence-Based Assessment

Question 1

Discuss the role of assessment as the starting point of all models of clinical reasoning.

Answer 1

Assessment is the collection of data about a patient's health state. Although the practitioner may collect subjective and objective data concurrently, it is important to distinguish between the two and to recognize that both are part of the data base. Subjective data consist of the information provided by the affected individual. Objective data comprise the information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies. The data base is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.

Question 2

Describe the use of diagnostic reasoning in clinical judgment.

Answer 2

The step from data collection to diagnosis can be difficult, especially for the beginning examiner. With the diagnostic reasoning model, collecting and analyzing health data are based on the scientific method. This model has four major components: (1) attending to initially available cues, (2) formulating diagnostic hypotheses, (3) gathering data relative to the tentative hypotheses, and (4) evaluating each hypothesis with the new data collected. The result is a final diagnosis. The examiner will gather cues, which are pieces of information, signs, symptoms, or laboratory data. A hypothesis is a tentative explanation for a cue or a set of cues and can serve as a basis for further investigation. Once data collection is completed, the examiner will cluster or group together cues (assessment data) that seem to be causal or associated. Data should be validated to ensure that they are accurate.
The use of a conceptual model helps to organize data.

Question 3

Discuss the use of the nursing process in clinical judgment.

Answer 3

The nursing process is also based on the scientific method, and it includes six phases: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. At first, this process was considered to be linear, but now it is considered a more dynamic, interactive process in which practitioners in today's more complex clinical settings move back and forth within the steps.

Question 4

Differentiate between novice, proficient, and expert practitioner.

Question 5

Describe the use of critical thinking in diagnostic reasoning and clinical judgment.

Question 6

Differentiate first-level, second-level, and third-level priority problems.

Question 7

Use a conceptual framework to guide nursing practice.

Question 8

Contrast medical diagnosis with nursing diagnosis.

Question 9

Discuss the expanded concept of health and relate it to the process of data collection.

Question 10

Relate the patient situation to the amount of data collected.

Question 11

Relate the patient age and health status to the frequency of health assessment.

Question 12

Consider life cycle and cross-cultural factors when performing a health assessment.

Question 13

Discuss the importance of high-level assessment skills.