Health assessment lec

• • Emergency Assessment: rapid assessment performed in life-threatening situations
• Review of the Phases of Nursing Process:

  • Assessment involves collecting subjective and objective data to plan and provide care for the client
  • Types of Assessment:
  • Initial comprehensive Assessment: Collection of subjective data about the client’s perception of health, past health history, family history, lifestyles, and health practices
  • On-going or Partial Assessment: mini-overview of the client’s body systems and holistic health patterns
  • Focus or Problem Oriented Assessment: thorough assessment of a particular client problem
• • Advocate: nurse notifies the proper healthcare team member of any problem requiring expert care for the patient
• Role of Nurses in Health Assessment:

  • Health assessments are used to gather information about a patient's condition
  • Nursing Diagnoses and Care Planning: nurse formulates diagnoses from identified problems to create a care plan
  • Managing Problems: nurse continuously assesses the patient to make changes to the care plan if needed
  • Evaluation: determines if a patient has responded to nursing care sufficiently for discharge
  • Discharge Teaching: nurse imparts information to improve the patient's condition before discharge
• • Documenting data as the data base for the entire nursing process
• Major Steps of Health Assessment in Nursing Process:

  • Collecting subjective data: includes biographical information, physical symptoms, reasons for seeking health care, past health history, family history, current medications, health and lifestyle practices, developmental level, psychosocial history
  • Collecting objective data: directly observed physical characteristics, body functions, appearance, measurements, and results of laboratory testing
  • Sources of Data: Primary data from the patient/client, Secondary data from family members
  • Validating assessment data to ensure accuracy
• Diagnosis:

  • Analyzing subjective/objective data to make a professional nursing judgment
  • Nursing diagnosis is a clinical judgment about individual, family, or community responses to health problems
  • Basis for collecting nursing interventions to achieve outcomes for which the nurse is accountable
• Planning:

  • Involves setting priorities, stating client goals/outcomes, and selecting nursing interventions
  • Activities during Planning: Prioritization, Outcome Criteria
• Implementation:

  • Carrying out the care plan through independent or dependent nursing actions/implementation
• Evaluation:

  • Assessing if outcome criteria have been met and revising the plan as necessary
  • Determines if the goal has been achieved within the stated time frame
• Health History Guidelines:

  • Interview: communication process focusing on establishing rapport, gathering information on the client’s statuses, and identifying deviations or strengths
  • Phases of Interview: Introductory/preparatory, Working or interaction, Summary and Closing Phase
  • Communication During the Interview:
  • Non-Verbal Communication: appearance, silence, listening, facial expression, attitude
  • Verbal Communication: open-ended questions, close-ended questions, laundry list, well-placed phrases, rephrasing, providing information, inferring
• • Special considerations during interview:
  • Gerontologic variations in communication
  • Cultural Variations in Communications
  • Emotional Variations in Communications