HA

• Health assessment is the collection, validation, organizing, and recording of patient's data on his health status
• Nursing assessment collects holistic subjective and objective data to determine a client's overall level of functioning for professional clinical judgment
• Nursing assessment focuses on identifying human responses to health problems and the patient's strengths
• Nursing assessment is different from medical assessment which focuses on the disease process, its effects on the patient, and treatment
• The nursing process involves critical thinking to apply evidence to caregiving and promoting human functions and responses to health and illness
• The nursing process includes the steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE)
• Types of assessment include Initial Comprehensive Assessment, Ongoing or Partial Assessment, Focused or Problem-Oriented Assessment, and Emergency Assessment
• Data collection sources include primary data from the patient and secondary data from family, significant others, health care team, medical records, and other sources
• The process of data analysis involves identifying abnormal data and strengths, clustering the data, drawing inferences, and identifying problems
• Validation in data analysis is the act of double-checking or verifying data to confirm accuracy and factual information
• Prioritizing data in health assessment involves considering the acuity of the problem, patient's perception, and situation to address life-threatening problems first
• Considerations in health assessment include the age and cultural background of the client, family emotions, and ethico-legal considerations like informed consent and data privacy
• The role of the nurse in health assessment has evolved over time from the late 1800s to the present
• Thinking critically is the way in which the nurse processes information using knowledge, past experience, intuition, and cognitive abilities to formulate conclusions or diagnoses
• Purpose of assessing a client’s health status is to analyze the subjective and objective data collected, including health promotion, diagnoses, risk diagnoses, actual diagnoses, collaborative problems, and referrals to health care providers for possible medical problems
• Data analysis can be challenging and requires the use of diagnostic reasoning skills to interpret data accurately
• Characteristics that a nurse must develop to think critically:

  • Keep an open mind
  • Use rationale to support opinions or decisions
  • Reflect on thoughts before reaching a conclusion
  • Use past clinical experiences to build knowledge
  • Acquire an adequate knowledge base that continues to build
  • Be aware of the interactions of others
  • Be aware of the environment
• Before analyzing the data, accurately perform the steps of the assessment phase of the nursing process, which include Collection and Organization of Assessment Data, Validation of Data, and Documentation of Data
• Guide in formulating questions: Remember the mnemonic “OLD CART” which stands for Onset, Location, Duration, Characteristic of symptoms, Associated manifestation, Relieving factors, and Treatments
• Subjective data (symptoms) is what the patient tells you, including the history from the Chief Complaint through Review of Systems. Objective data (signs) is what you detect during the examination, including all physical examination findings
• The process of clinical reasoning involves identifying problems and making diagnoses, clustering findings, interpreting findings, making hypotheses about the nature of the patient’s problem, testing the hypotheses, establishing a working diagnosis, developing a plan agreeable to the patient, and documenting conclusions
• Challenges of clinical data include clustering data into single vs multiple problems, assessing the quality of the data, and sifting through an extensive array of data
• Tips for ensuring the quality of data:

  • Ask open-ended questions and listen carefully
  • If the patient answers “YES”, continue using “OLD CART”
  • Follow a thorough and systematic sequence
  • Keep an open mind
  • Always include “the worst-case scenario”
  • Analyze any mistakes in data collection
  • Confer and review pertinent literature
  • Apply principles of data analysis
• Cultural competency requires healthcare providers to be sensitive to patients' heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural backgrounds
• Cultural humility involves recognizing one’s limitations in knowledge, being open to new perspectives, avoiding assuming all patients of a particular culture fit a certain stereotype, engaging in self-reflection and self-critique, and having a genuine interest in understanding patients' belief systems and lives
• Three dimensions of cultural humility:

  • Self-awareness: exploring your own cultural identity
  • Respectful communication: letting patients be the experts on their own unique cultural perspective
  • Collaborative partnership: building patient relationships on respect and mutually acceptable plans
• The impact of culture includes racial and ethnic differences, as well as social and economic conditions, affecting the provision of specific healthcare services
• Interprofessional care involves a culture shift in the health professions towards harmony and unity in patient care that is not constricted by cultural and administrative boundaries
• Components of a cultural response that will impact patients include diet and nutrition, health beliefs and practices, modes of communication, and the nature of the relationship
• As healthcare providers, there is a compelling need to meet each patient on their own terms and to resist forming a sense of the patient based on prior knowledge of race, religion, gender, ethnicity, sexual identity and orientation, or culture
• Remember the RESPECT model:

  • R: Rapport
  • E: Empathy
  • S: Support
  • P: Partnership
  • E: Explanations
  • C: Cultural competence
  • T: Trust
• General survey assessment observes the entire patient as a whole
• Begins with initial patient contact and continues throughout the helping relationship
• Nurse's objective observation of the patient starts with the first moments of the encounter
• First step in head-to-toe assessment determines reasons client is seeking health care
• Observation of client's general appearance, level of comfort, vital signs, height, and weight
• Provides information about illness characteristics, hygiene, body image, emotional state, recent weight changes, and development status
• Vital signs include BP, HR, RR, temperature, and pain (5th vital sign)
• Blood pressure steps for accurate measurement:

  • Instruct patient to avoid smoking or drinking caffeinated beverages for 30 minutes
  • Ensure quiet and warm examining room
  • Ask patient to sit quietly for at least 5 minutes with feet flat on the floor and hands supported at heart level
  • Palpate brachial artery for viable pulse
  • Position arm so brachial artery is at heart level
  • Errors resulting in false high/low readings
• Heart rate and rhythm (pulse rate) normal range: 60-100 bpm

  • Elevated: Tachycardia (>160 bpm)
  • Below: Bradycardia (<60 bpm)
  • Respiratory rate normal range: 12-20 cpm
  • Elevated: Tachypnea (>20 cpm)
  • Below: Bradypnea (<12 cpm)
  • Temperature usual normal range: 36°C-37.5°C
  • Elevated: Hyperthermia (>37.5°C)
  • Below: Hypothermia (<36°C)