Evidence- Based Assessment

 Every interaction is part of the nursing

process.
 Nursing process = six steps:

- Assessment, Diagnosis, Planning,

Implementation, Evaluation.
 First step: Assessment
 Components of health assessment
◦ Health history
◦ Physical examination
◦ Documentation of data
 Three primary components
 History (subjective data)
 Examination (objective data)
 Documentation of data
 Data = signs and symptoms
 Symptom = what client feels/communicates
(subjective)
 Sign = clinical finding (objective)
 Clinical manifestations = signs and/or symptoms
experienced by client
Dataanalysis, interpretation, and clinical
judgment includes
◦ Identification of abnormal findings
◦ Correctly interpreting findings to select appropriate
interventions
◦ Clinical judgment to interpret or make conclusions
regarding patient needs, concerns, or health
problems of the patient.
 Amount of information gained during a
health assessment depends on several
factors including:
 Context of care
 Client need
 Expertise of the nurse
 Client needs vary widely.
 Nurse must be prepared to conduct appropriate
level of assessment.
 Client’s age, general level of health, presenting
problems, knowledge level, and support systems
are among the variables that impact client need.
 Expertise of the nurse is gained with
specialization within a given area of
practice; for example:
 A nurse in an adult intensive care unit has
expertise assessing a client with hemodynamic
instability.
 A family nurse practitioner working in a
women’s clinic has expertise in performing
routine pelvic examinations.