Introduction to Health Assessment

• Diagnosing phase involves analyzing and synthesizing data to identify client strengths and health problems that can be prevented or resolved by nursing interventions
• Planning phase involves determining how to prevent, reduce, or resolve identified priority client problems, support client strengths, and implement nursing interventions in an organized, individualized, and goal-directed manner
• Implementing phase involves carrying out or delegating planned nursing interventions to assist the client in meeting desired goals/outcomes, promoting wellness, preventing illness, restoring health, and facilitating coping with altered functioning
• Evaluating phase involves measuring the degree to which goals/outcomes have been achieved, identifying factors that influence goal achievement, and determining whether to continue, modify, or terminate the plan of care
• Characteristics of nursing process:

  • Cyclical and dynamic in nature
  • Client-centered
  • Focus on problem-solving and decision-making
  • Different but parallel to the process used by physicians
  • Interpersonal and collaborative style
  • Universally applicable
  • Use of critical thinking
• Critical thinking in nursing is a discipline-specific, reflective reasoning process that guides nurses in generating, implementing, and evaluating approaches for dealing with client care and professional concerns
• Components of critical thinking include critical analysis, inductive and deductive reasoning, making valid inferences, differentiating facts from opinions, evaluating the credibility of information, clarifying concepts, and recognizing assumptions
• Health assessment involves a comprehensive assessment of one's health status with two primary components: Nursing Health History and Physical Assessment
• Purposes of health assessment:

  1. To obtain baseline data

  2. To supplement, confirm, or refute data

  3. To establish nursing diagnoses and plans of care

  4. To evaluate physiological outcomes of health care

  5. To make clinical judgments

  6. To identify areas for health promotion and disease prevention
• Assessment is a systematic and continuous collection, organization, validation, and documentation of data carried out during all phases of the nursing process to establish a database
• Activities in assessment:

  • Collecting Data
  • Organizing Data
  • Validating Data
  • Documenting Data
• Data collection involves gathering information about a client's health status through systematic and continuous methods, including nursing health history, physical assessment, primary care provider's history, physical examination, and results of laboratory and diagnostic tests
• Types of data:

  • Subjective data (symptoms)
  • Objective data (signs)
  • Constant data
  • Variable data
• Sources of data:

  • Primary (client)
  • Secondary (family, support persons, other health professionals, medical records and reports, laboratory and diagnostic, relevant literature)
• Data collection methods:

  • Observation
  • Interview
  • Examining
• Observing involves gathering data using the senses, noticing data, and selecting, organizing, and interpreting the data consciously and deliberately
• Interviewing is a planned communication or conversation with a purpose, such as getting or giving information, identifying problems, evaluating change, teaching, providing support, counseling, or therapy
• Types of interview questions:

  • Closed questions
  • Open-ended questions
  • Neutral questions
  • Leading questions
• Factors to be considered during an interview:

  • Reviewing available information
  • Time
  • Place
  • Seating arrangement
  • Distance
  • Language
• The nurse must convert complicated medical terminology into common English usage
• Interpreters or translators are needed if the client and the nurse do not speak the same language or dialect
• The opening of the interview is crucial as it sets the tone for the remainder of the interview
• The purposes of the opening are to establish rapport and orient the interviewee
• Establishing rapport is a process of creating goodwill and trust
• In the body of the interview, the client communicates thoughts, feelings, knowledge, and perceptions in response to questions from the nurse
• The nurse terminates the interview when the needed information has been obtained
• The closing is important for maintaining rapport and trust, and for facilitating future interactions
• Physical examination is a systematic data collection method using observation to detect health problems
• Techniques used in physical examination include inspection, auscultation, palpation, and percussion
• The head-to-toe approach begins the examination at the head, progresses to the neck, thorax, abdomen, extremities, and ends at the toes
• Screening examination is a brief review of essential functioning of various body parts or systems
• The nurse organizes assessment data systematically in the form of nursing health history, nursing assessment, and nursing database form
• Gordon’s Functional Health Pattern is a conceptual model/framework used in health assessment
• Orem’s Self-Care Model is a conceptual model/framework used in health assessment
• Roy’s Adaptation Model is a conceptual model/framework used in health assessment
• Wellness Model is a conceptual model/framework used in health assessment
• Non-nursing Model includes Body Systems Model, Maslow’s Hierarchy of Needs, and Developmental Theories (Freud’s)
• Validation is the act of double-checking or verifying data to confirm accuracy and factualness
• Cues are subjective or objective data directly observed by the nurse
• Inferences are the nurse’s interpretations or conclusions based on cues