NCM 101 LEC HEALTH ASSESMENT

• Health assessment involves the promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human responses, and advocacy in the care of individuals, families, communities, and populations
• Nursing process is a series of organized steps designed for nurses to provide excellent care
• The nursing process is flexible and rigid
• Overview of Nursing Process:
• It is one of the foundations of practice and offers a framework for critical thinking skills
• Assessment
• Implementation
• Planning
• Diagnosis
• Evaluation
• Collect data, organize data, validate data, and document data
• Subjective information is the client's perception, while objective information is the nurse's observation
• Assessment:
• Data must be organized before coming up with a solution for the client's condition
• Data validation is crucial before finalizing the solution
• Diagnosing:
• Analyze data, identify health problems, risks, and strengths, and formulate diagnostic statements
• Nursing diagnosis involves analyzing subjective and objective data to make professional judgments
• Collaborative problems may require referral to other healthcare team members
• Planning:
• Prioritize problems/diagnosis, formulate goals/desired outcomes, select nursing interventions, and write nursing interventions
• Determine outcome criteria and develop a nursing care plan
• Implementing:
• Reassess the client, determine the need for assistance, implement nursing interventions, supervise delegated care, and document nursing activities
• Reassess the client to evaluate the effectiveness of the plan
• Evaluating:
• Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status, and continue, modify, or terminate the client's care plan
• Assess whether outcome criteria have been met and revise the plan as necessary
• If goals are partially met, review the care plan and actions to promote the client's condition
• Health assessment involves the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human responses, and advocacy in the care of individuals, families, communities, and populations
• The registered nurse collects comprehensive data pertinent to the patient's health or situation
• Health assessment involves a thorough and dynamic action using the different phases of the nursing process
• Prioritizes data collection activities based on the patient's immediate condition or anticipated needs
• Uses appropriate evidence-based assessment techniques and instruments
• Types of Assessment:
• Initial Comprehensive Assessment (ICA)
• Ongoing or Partial Assessment (OPA)
• Focused or Problem-Oriented Assessment (FPOA)
• Emergency Assessment (EA)
• Time-Lapsed Assessment (TLA)