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Jarvis: Physical Examination & Health Assessment, 2nd Canadian Edition
Chapter 01: Critical Thinking and Evidence-Informed Assessment
Instructor’s Manual
ANNOTATED LEARNING OUTCOMES
After completing this chapter, the student will do the following:
Discuss the role of assessment as the starting point of all models of clinical reasoning.
Assessment is the collection of data on a patient’s state of health. Although the practitioner may
collect subjective and objective data concurrently, it is important to distinguish between the two
and to recognize that both are parts of the database. Subjective data consist of information
provided by the affected individual. Objective data consist of information obtained by the health
care provider through physical assessment, the patient’s record, and laboratory studies. The
database is the totality of available information about the patient. The purpose of assessment is to
make a judgement or diagnosis.
Describe the use of diagnostic reasoning in clinical judgement.
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 critical
decision making around the data gathered. 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.
Discuss how the nursing process is used in clinical judgement.
The nursing process is also based on the scientific method, and it includes six phases: (1)
assessment, (2) diagnosis, (3) outcome identification, (4) planning, (5) implementation, and (6)
evaluation. At first this process was considered to be linear, but now it is considered a more
dynamic and interactive process in which practitioners in today’s more complex clinical settings
move back and forth between the steps.
Differentiate between novice, proficient, and expert practitioner
The nursing process alone does not explain the dynamic and interactive processes that occur with
diagnosis and treatment planning. Although the nursing process is a logical challenge-solving
approach to clinical judgements, the way nurses apply the process depends on the amount and
level of their experience. The novice nurse has no experience with specific patient populations
and uses rules to guide performance. It may take two to three years for the novice nurse to
achieve competence in similar clinical situations. With more time and experience, the proficient
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nurse understands a patient situation as a whole rather than 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
labelling it.
Describe how critical thinking is used in diagnostic reasoning and clinical judgement.
Critical thinking is required for sound diagnostic reasoning and clinical judgement. Seventeen
critical thinking skills have been identified and are presented in the logical order in which they
might be used in the nursing process. However, rather than a step-by-step approach, critical
thinking is a multidimensional process. With experience, the new examiner will be able to apply
these skills in a rapid, dynamic, and interactive way.
Differentiate first-, second-, and third-level priority problems.
The nurse needs to quickly determine the priority levels of patient challenges. First-level priority
problems are immediate priorities that relate to the “ABCs”—airway problems, breathing
problems, cardiac and circulatory problems, and signs (i.e., vital signs). Second-level priority
problems are immediate but occur after treatment for first-level problems is started. Examples of
second-level priority problems include changes in mental status, acute pain, untreated medical
challenges, 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.
Collaborative problems are physiological complications in which the approach to treatment
encompasses multiple disciplines (such as alcohol withdrawal, which affects the central nervous
and cardiovascular systems). Nurses have the primary responsibility to diagnose the onset and
monitor changes in status.
Use a conceptual framework to guide nursing practice.
The organization of assessment data (the database) varies, depending on the conceptual model
used. The model provides the framework for 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 Watson.
Contrast medical diagnosis with 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 challenge on the whole person and with the individual’s response to the challenge. Both
the nursing diagnosis and the classification systems for intervention and outcome provide a
common language with which to communicate.
Discuss 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 data to be collected vary 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
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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 health promotion and disease
prevention. Within the behavioural model, the behaviours that promote health or that may cause
illness must be identified. Counselling is provided to encourage or enhance health-promoting
behaviours. The socioenvironmental model encompasses the biomedical and behavioural aspects
of health and includes sociological and environmental factors. The Ottawa Charter for Health
Promotion identified prerequisites to health and emphasizes the importance of increasing control
over the social determinants of health.
Relate the patient’s situation to the amount of data collected.
The practitioner must modify the approach to data collection according to the presenting clinical
situation. A health care provider in an emergency department will need to assess airway,
breathing, and circulation, and perform a problem-focused examination. An individual who is
gathering data for a complete health history and physical examination usually examines each
system in depth. Four different types of clinical situations and related databases are identified:
(1) complete (or total health) database, (2) episodic or problem-centred database, (3) follow-up
database, and (4) emergency database. After identifying the type of database indicated, the
practitioner must gather the correct data. The database will form the basis of one or more nursing
diagnoses.
Relate the patient’s age and health status to the frequency of health assessment.
At one time, periodic health examinations (frequently yearly) were recommended for all adults.
The 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 a consideration of
the whole person when providing health care. Age-specific charts for periodic health
examination can be used as schedules for health care. The focus is on the major risk factors that
are specific for each age group. In addition, health education and counselling are highlighted as
means to promote health. Evidence-informed clinical guidelines developed by the Canadian
Task Force on Preventive Health Care provide health care providers with screening and
counselling guidelines for health promotion.
Consider 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 the health care provider to which physical, psychosocial,
cognitive, and behavioural 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 patient’s life cycle stage to guide activities for health promotion and
health teaching.
Assessment factors must also include culture. Demographic trends indicate that the
cultural diversity of Canada is growing. The consideration of heritage in health assessment is
important for gathering accurate and meaningful data as well as for ensuring that interventions
are carried out with cultural sensitivity and appropriate care. Because of the multicultural
composition of Canada and the projected increase in the number of persons of various cultural
backgrounds, concern for the cultural beliefs and practices of people is becoming more important.
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Discuss the importance of high-level assessment skills.
In many community settings, the nurse is the first and often only health care provider who is
continually present at the bedside. It is increasingly important that assessment skills be practised
(with hands-on experience) and refined to a high level. Current cost-containment and budgetcutting efforts have led to a hospital patient population characterized by 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 challenges.
KEY TERMS
Assessment
Behavioural model
Biomedical model
Complete database
Critical thinking
Diagnostic reasoning
Emergency database
Episodic database
Evidence-informed practice
Follow-up database
Health promotion
Medical diagnosis
Nursing diagnosis
Nursing process
Objective data
Relational practice
Social determinants of health
Socioenvironmental model
Subjective data
TEACHING STRATEGIES
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Using available problems, have students identify the four major components of diagnostic
reasoning followed for each problem.
Using existing problems, have students identify the steps of the nursing process for each
problem.
Using patient records at clinical agencies used by your school of nursing, have students
review the available database as part of the evaluation step of the nursing process.
Discuss the nursing process as a linear process, as opposed to a circular process.
As a small-group or in-class exercise, choose a patient scenario and “walk through” the 17
critical thinking skills listed in Chapter 1, applying each one to the scenario.
Apply various nursing theories to the clinical situations described in the Student Lab Manual.
Discuss how each theory affects the direction of the interview and the interventions planned.
Have students conduct a “health fair” at one of the school’s clinical agencies or at a local
educational institution. Both the skills and the materials obtained or developed for each
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chapter can be used for the fair. Be sure to have the students consider the age-appropriate and
socioculturally appropriate aspects of the setting chosen for the health fair.
Using professional journals or newspaper or magazine articles as a basis for identifying
health problems, have students describe the type of data collection indicated (i.e., complete
[total health], episodic, follow-up, or emergency).
Using the age-specific chart for periodic health examinations, have students identify a patient
and design a schedule for regular health visits and preventive services, as well as health
promotion activities for that individual patient.
Discuss the demographics of the area in which you live, and have the students develop a list
of appropriate cross-cultural considerations for the ethnic groups in your area.
CRITICAL THINKING EXERCISES
Application to Clinical Practice
For each situation described below, have students identify the subjective and objective data, at
least one nursing diagnosis, additional factors that might should be described, and (if the
situation indicates) a complete, episodic, follow-up, or emergency database. Design a periodic
health examination schedule for each patient, based on the age-specific chart. Include wellness,
health promotion, and disease prevention activities. If other than a complete examination is
required, have students identify the body system(s) that must be focused on. Have students also
discuss developmental, socioeconomic, and cross-cultural considerations for each situation.
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P.D. is brought to the emergency department with the complaint of a sore shoulder. He states
that he was forced off the road while riding his motorcycle and sideswiped a telephone pole.
He did not lose consciousness. A urine specimen reveals gross hematuria. P.D. also states
that the MP3 player in the right pocket of his leather jacket was shattered.
A family consisting of a mother aged 33 years, a father aged 29 years, and two children aged
6 months and 3 years come to the local health clinic. The adults state that they have recently
relocated to this area and are interested in finding a health care provider. When asked, the
mother says they have no known health problems. During the interview with the parents, you
note the 3-year-old playing with a puzzle.
M.G., known to the health care provider, comes to the local diabetes centre. Her last visit was
six months before this one. M.G. brings a record of her blood glucose levels and insulin
dosages for the past six months. When asked how she has been feeling, she states that she has
a sore foot from playing tennis two weeks ago, but otherwise feels well.
G.M., known to the health centre, calls for an emergency appointment, complaining of a sore
throat and an earache. On examination, both the pharynx and eardrum appear reddened.
J.P. is a 65-year-old man of African descent who comes into the clinic for a periodic health
visit. He has a history of hypertension. During the visit, he has no complaints other than
having to wake up frequently to urinate.
L.M., a 20-year-old Aboriginal woman, is visiting the clinic for the first time. While taking
her history, you discover that she is pregnant but is unsure of the date of conception. She says
she had her last period in April (it is now August). She is married and has her 15-month-old
son with her.
S.T., a 16-year-old high school student, is visiting the clinic for the first time because she has
a boyfriend and is worried because they have started having intercourse.
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WEB SITES OF INTEREST
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Canadian Nurses Association—http://www.cna-aiic.ca
Public Health Agency of Canada—http://www.phac-aspc.gc.ca/index-eng.php
Canadian Student Nurse Association—http://www.cnsa.ca
NANDA International—http://www.nanda.org
Health Canada—http://www.hc-sc.gc.ca/index-eng.php
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OPEN-BOOK QUIZ
Chapter 1: Critical Thinking and Evidence-Informed Assessment
Provide the missing words or phrases for each of the following statements.
1. __________ __________ is a method, based on the scientific method, that helps the
examiner analyze information.
2. _______________ health views the mind, body, and spirit as interdependent and functioning
as a whole in the environment.
3. Data are collected during the _______________ phase of the nursing process.
4. __________ __________ comprise the data observed by the health care provider during the
physical examination.
5. __________ __________ comprise the data obtained from what a person says about himself
or herself during history taking or assessment.
6. A _______________ is a piece of information, a sign or symptom, or a piece of laboratory
data.
7. During the __________ __________ phase of the nursing process, priorities and outcomes
are established.
8. The last phase of the nursing process is the _______________ phase.
9. Expert nurses use knowledge that is received as a whole and characterized by an immediate
recognition of patterns. This type of knowledge is called _______________.
10. During the _______________ phase of the nursing process, priorities are established and
outcomes are developed.
11. Problems that are emergent, life-threatening, and immediate are known as _______________ priority problems.
12. Problems that involve numerous disciplines with the approach to treatment are known as
_______________ problems.
13. Expected outcomes should be _______________ and include a specific _______________.
14. Checking the accuracy and reliability of data is known as _______________.