Chapter 2

Critical Thinking in Health

Assessment

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

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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

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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.

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 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?

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

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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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

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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

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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

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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

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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

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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

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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

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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

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

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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

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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

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