Chapter 1 Study Guide Physical Examination and Health Assessment

Chapter One Study Guide
Evidence-Based Assessment Chp. 1
Subjective Data: what the person says about himself or herself during history taking
Objective Data: what you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination.
Database: subjective data, objective data, and the patient’s records and laboratory studies.
From the database, you make a clinical judgment or diagnosis about the individual’s health state or response to actual or risk health problems and life processes, as well as diagnoses about higher levels of wellness. Thus the purpose of assessment is to make a judgment or diagnosis.
Diagnostic Reasoning: an organized assessment is the starting point of diagnostic reasoning. Diagnostic reasoning is the process of analyzing health data and drawing conclusions to identify diagnoses. Novice examiners most often use a diagnostic process involving hypothesis forming and deductive reasoning. It has four major components:
1. Attending to initially available cues
2. Formulating diagnostic hypothesis
3. Gathering data relative to the tentative hypotheses
4. Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis
A cue is a piece of information, a sign or symptom, or a piece of laboratory data
A hypothesis is a tentative explanation for a cue or a set of cues that can be used as a basis for further investigation
Critical Thinking and the Diagnostic Process: The standards of practice in nursing, or the nursing process
1. Assessment
Collect data:
Review of the clinical record
Health history
Physical examination
Functional assessment
Risk assessment
Review of the literature
Use evidence-based assessment techniques
Document relevant data
2. Diagnosis
Compare clinical findings with normal and abnormal variation and developmental events
Interpret data
Identify clusters of clues
Make hypotheses
Test hypotheses
Derive diagnoses
Validate diagnoses
Document diagnoses
3. Outcome identification
Identify expected outcomes
Individualize to the person
Culturally appropriate
Realistic and measurable
Include a timeline
4. Planning
Establish priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
Document plan of care
5. Implementation
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
Document implementation and any modification
6. Evaluation
Progress toward outcomes
Conduct systematic, ongoing, criterion-based evaluation
Include patient and significant others
Use ongoing assessment to revise diagnoses, outcomes, plan
Disseminate results to patient and family
The novice nurse: has no experience with a specified patient population and uses rules to guide performance.
The competency nurse: it takes perhaps 2 to 3 years in similar clinical situations to achieve competency, in which you see actions in the context of arching goals or daily plans for patients.
The proficient nurse: understands a patient situation as a whole rather than as a list of tasks. You can see long-term goals for the patient and how today’s interventions apply to the point you want the patient to be in, say, 6 weeks.
Expert nurse: vault over the steps and arrives at a clinical judgment in one leap. Has an intuitive grasp of a clinical situation and zeroes in on the accurate solution.
Critical Thinking:
1. Identifying assumption: recognize that you could take information for granted or see it as fact when actually there is no evidence for it. Ask yourself, “What am I taking for granted here?”
2. Identifying an organized and comprehensive approach to assessment. This depends on the patient’s priority needs and your personal or institutional preference. Head-to-toe approach, a body systems approach, a regional area, or the use of a preprinted assessment form developed by the hospital or clinic.
3. Validation, or checking the accuracy and reliability of data.
4. Distinguishing normal from abnormal when identifying signs and symptoms. Spotting abnormal signs and symptoms leads to problem identification. At first it is difficult to discriminate abnormal signs and symptoms versus what is expected for the patient’s age, gender, culture, and lifestyle.
5. Making inferences or hypotheses. This involves interpreting the data and deriving a correct conclusion about the health status. This presents a challenge for the beginning examiner, because it needs a baseline amount of knowledge and experience.
6. Clustering related cues, which will help you see relationships among the data. Exp. Heavy alcohol use, social consequences of alcohol use, academic consequences, and occupational consequences are a clustering of cues that suggest a maladaptive pattern of alcohol use.
7. Distinguishing relevant form irrelevant. A complete history and physical examination furnish a vast amount of data. Look at the clusters of data, and consider which data are important for a health problem or a health promotion need. This skill is also a challenge for beginning examiners and one area where a clinical mentor can be invaluable.
8. Recognizing inconsistencies.
9. Identifying patterns. This helps fill in the whole picture and discover missing pieces of information.
10. Identifying missing information, gaps in data, or a need for more data to make a diagnosis.
11. Promoting health by identifying risk factors. This applies to generally healthy people and concerns disease prevention and health promotion. You need to identify and manage known risk factors for the individual’s age-group and cultural status. This will drive your wellness diagnosis.
12. Diagnosing actual and potential (risk) problems from the assessment data. The biomedical focus is the diagnosis and treatment of the specific agents for pathogens that cause disease. Assessment factors are a list of biophysical symptoms and sigs. The person is certified as healthy when these symptoms and signs have been eliminated. When disease does exist, medical diagnoses are worded to identify and explain the cause of disease.

Key Points
1. The role of assessment as the starting point of all models of clinical reasoning. 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 consists 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.
2. The use of diagnostic reasoning in clinical judgment. 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.
3. The use of nursing process in clinical judgment. 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 more back and forth within the steps.
4. The difference between novice, proficient, and expert practitioner. The nursing process alone does not explain the dynamic and interactive processes that occur with diagnosis and planning of treatment. Although the nursing process is a logical problem-solving approach to clinical judgments, the way nurses apply the process depends on their level of time and experience. The novice nurse has no experience with specific patient populations and uses rules to guide performance. It may take 2 to 3 years for the novice nurse to achieve competence in similar clinical situations. After more time and experience, the proficient nurse understands a patient situation as a whole rather than as a list of tasks. The expert nurse has an intuitive grasp of a clinical situation and zeroes in on the accurate solution. The expert practitioner learns to attend to a pattern of assessment data and to act without consciously labeling it.
5. The use of critical thinking in diagnostic reasoning and clinical judgment. Critical thinking is required for sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been identified and are presented in an order that is the logical progression of the ways the skills might be used in the nursing process. However, rather than being used in a step-by-step way, critical thinking is a multidimensional thinking process, and with experience, the new examiner will be able to apply these skills in a rapid, dynamic, and interactive way.
6. The difference between first-level, second-level, and third-level priority problems. 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 are started. Examples of second-level problems include metal 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.
7. The use of a conceptual framework to guide nursing practice. The organization of assessment data (the data base) varies, depending on the conceptual model that is used. A model provides the framework in determining what to observe, how to organize the observations or data, and how to interpret and use the information. Although many different conceptual models exist, they all deal with the same concepts: human beings, environment and society, health and illness, and nursing. Examples of nursing models include those of Orem, Roy, Leininger, and Gordon.
8. The contrast between medical diagnosis and nursing diagnosis. Medical diagnosis and nursing diagnosis are independent but interrelated. Medical diagnosis is concerned with the etiology of disease. Nursing diagnosis is concerned with the impact of the health problem on the whole person and with the individual’s response to the problem. Both the nursing diagnosis and the classification systems for intervention and outcome provide a common language with which to communicate.
9. The expanded concept of health and relate it to the process of data collection. The concept of health has expanded over time and is based on the practice model used. Because of this expanded definition, the list of data to be collected varies according to the practice model used. The biomedical model of Western medicine views health as the absence of disease. With this view, the focus of data collection is on biophysical signs and symptoms and on curing disease. Wellness, a dynamic process, is a move toward optimal functioning. Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together. The concept of health has also been expanded to include the concept of health promotion and disease prevention. The behaviors that promote health or may cause illness must be identified. Counseling is provided to promote or enhance health-promoting behaviors
10. Relating the patient situation to the amount of data collected. 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.
11. Relating the patient age and health status to the frequency of health assessment. At one time, periodic health examinations, frequently yearly, were recommended for all adults. Frequency of health visits is now based on preventive services for each age group and is individualized for each patient. This change in frequency is more reflective of considering the whole person when providing health care. The age-specific charts for periodic health examination can be used as a schedule for health care. The focus is on major risk factors specific for each age group. In addition, health education and counseling are highlighted as the means to deliver health promotion.
12. Considering life cycle and cross-cultural factors when performing a health assessment. Consideration of the usual and expected developmental tasks for each age group is an important part of the health assessment. This alerts one to which physical, psychosocial, cognitive, and behavioral tasks are currently important for each person. A holistic approach to health assessment arises from an orientation toward wellness and health maintenance. The practitioner can use the person’s life cycle state to direct activities for health promotion and health teaching. In addition, assessment factors must include culture. Demographic trends indicate that the cultural diversity of the United States is growing. The inclusion of heritage assessment in health assessment is important to gather data that are accurate and meaningful as well as to intervene with culturally sensitive and appropriate care. Because of the multicultural composition of the United States and the projected increase in the number of persons from various cultural backgrounds predicted for the future, a concern for the cultural beliefs and practices of people is becoming more important.
13. The importance of high-level assessment skills. 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.