Health assessment in nursing

• Health is the relative state in which a person is able to live to his or her potential
• Includes the 7 facets of health: physical, environmental, emotional, developmental, social, spiritual, and cultural
• Health assessment is the processes used to evaluate the health status of a person
• Consists of:

  • Comprehensive health history
  • Complete physical examination
• Health history includes:

  • Demographic data
  • Chief complaint
  • History of present illness
  • Past medical history
  • Past psychological issues
  • Family history
  • Personal/social history
  • Cultural history
  • Spiritual beliefs
  • Review of systems
• Purpose of health assessment:

  • To determine the health status
  • To determine the patient's risk factors
  • To determine the need for health education
  • Develop nursing plan of care
• Every person needs to have a complete assessment, ideally done on admission
• Nursing vs medical assessments:

  • Nursing focuses on diagnoses and treatment of actual or potential human responses
  • Identifies many contributing factors to individual health and wellness
  • Medical focus is on the diagnosis and treatment of the disease
• Nurse detects areas of concern requiring immediate attention and uses findings to decide the areas that take precedence
• Health promotion and disease prevention are essential areas of patient education
• Health care team includes:

  • Nurse
  • Physician
  • Nutritionist
  • Social workers
  • Physical therapist
  • Occupational therapist
  • Speech therapist
  • Dentist
• Additional components of health assessment:

  • Individual's personality and attitude
  • Resilience
  • Family dynamics and access to healthcare and resources
  • Nutrition
  • Exercise
  • Culture and beliefs
• Types of Health Assessment
• Collection of subjective data about the client's health all body parts or past medical history, family history, and lifestyle and health practices
• Ongoing or Partial Assessment:

  • Data collection that occurs after the comprehensive database is established
• Focused/Problem Oriented Assessment:

  • Thorough assessment of a particular client problem, which does not cover areas not related to the problem
• Emergency Assessment:

  • Very rapid assessment performed in life-threatening situations
  • Assessment of the carotid pulse is vital in an emergency assessment
• Major Steps in Assessment
• Objective Data Collection:

  • The examiner directly observes objective data or signs, including physical characteristics, body functions, appearance, behavior, measurements, results of laboratory testing, utilization of 4 P.E. Techniques (IPPA), and other sources such as client's medical record or family or significant other's observation
• Subjective Data Collection:

  • Sensations or symptoms elicited and verified by the client, including biographical information, history of present health concern, personal health history, family history, and health & lifestyle practices
• Data Validation:

  • Crucial part of assessment to ensure all relevant data have been collected, validate data, identify areas where data are missing
• Data Documentation:

  • Forms the database for the entire nursing process and provides data for all other members of the health care team
  • Ensure valid conclusions are made when data are analyzed in the second step of the nursing process
• Data Analysis:

  • Often called nursing diagnosis
  • Purpose is to arrive at conclusions about the client's health
  • Nurses analyze data during assessment to ensure accuracy and thoroughness
  • This phase analyzes and synthesizes data
• Data documentation forms the database for the entire nursing process and provides data for all other members of the health care team
• Ensures that valid conclusions are made when data are analyzed in the second step of the nursing process
• Data analysis is often called nursing diagnosis
• The purpose of assessment is to arrive at conclusions about the client's health
• Nurses often begin to analyze the data in their minds while assessing and ensure that the data collected are as accurate and thorough as possible
• The process of data analysis involves documenting conclusions, clustering data, identifying abnormal data and strengths, drawing inferences and identifying problems, proposing possible nursing diagnoses, checking for defining characteristics of those diagnoses, and confirming or ruling out nursing diagnoses
• Factors affecting health assessment include the client's culture, family, and community, as well as spirituality
• In the late 1800s to early 1900s, physical assessment was seen as an integral part of nursing, with nurses relying on natural senses and using palpation
• In the 1950s to 1969, nurses were hired to conduct pre-employment health stories and physical examinations for major companies
• From 1970 to 1989, nurses developed an active role in providing primary health services and expanded their professional role
• From the 1990s to the present, the nurse's role in holistic assessment has been solidified, with a demand for documentation of client assessments by all health care providers
• The nursing process is a systematic, rational method of planning and providing individualized nursing care
• It is the underlying scheme that provides order and direction to nursing care
• It is the essence of professional nursing practice
• It is cyclical, with components following a logical sequence, but more than one component may be involved at any one time
• The purpose of the nursing process is to identify a client's health status, actual or potential health care problems or needs, establish plans to meet the identified needs, and deliver specific nursing interventions to meet those needs
• It helps nurses in arriving at decisions and in predicting and evaluating consequences