Introduction to Health Assessment

• Nursing process

  This term were used by Hall (1955), Johnson (1959), Orlando (1961), Wiedenbach (1963), ANA (1973)
• Nursing process

  It systematic; rational method of planning and providing individualized nursing care
• According to Lydia Hall, it is an organized, systematic goal-oriented, humanistic care
• Critical thinking

  It is discipline-specific and reflective reasoning process
• Health Assessment

  It is a comprehensive assessment of one’s health status
• 2 Primary Components of Health Assessment

  • Nursing Health History

  • Physical Assessment
• Assessment

  It is a systematic and continuous collection, organization, validation, and documentation of data
• All phases of the nursing process depend on the accurate and complete action of data
• Purpose of Assessment: Establish a database
• Collection of Data

  Formulation of database which contains:

  • Nursing Health History

  • Physical Assessment

  • Primary Care Provider’s History

  • Physical Examination

  • Results of laboratory and diagnostic tests
• Subjective data

  Symptoms
• Objective data

  Signs
• Client

  Primary source of data
• Family, support persons, other health professionals

  Secondary Sources of Data
• Data Collection Methods

  Observation — using senses

  Interview — planned communication or a conversation
• Directive

  Nurse establishes purpose of the interview and controls the interview
• Close-ended questions

  Directive interview
• Open-ended questions

  Non-directive, invite clients to discover and explore etc
• Neutral questions

  Without direction or pressure from the nurse
• Leading

  Closed, directive interview
• Physical examination or physical assessment is a systematic data collection method that uses observation
• Validation

  Act of “double-checking” or verifying data to confirm that it is accurate and factual
• Initial Comprehensive Assessment

  • Perception of health

  • Past health history

  • Lifestyle and health practices

  • Objective and subjective data
• Ongoing or Partial Assessment

  Data collection that occurs after a comprehensive database is established
• Focused or Problem oriented Assessment

  Done when a patient came to the health care agency with a specific health concern
• Emergency Assesment

  Very rapid assessment performed in life-threatening situation
• Framework

  A basic structure underlying a process, system, concept or text
• Functional Health Framework

  Evaluates the effects of mind, body, and environment in relation to a person’s ability to perform
• Cephalocaudal Framework

  System data in an organized manner: head to toe
• Body System Framework

  A framework that medical practitioners commonly use; it focuses more on the pathophysiology and assessment of an acutely or critically ill client
• Critical Thinking in Health Assessment

  A purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning
• Critical thinking in health assessment combines logic, intuition and creativity
• Clinical reasoning

  A disciplined, creative, and reflective approach used together with critical thinking
• The purpose of clinical reasoning is to establish potential strategies to assist patients in reaching their desired health goals
• Interpretation

  Decode hidden messages, clarify the meaning of the information, categorize the information
• Analysis

  Ideas and data presented, identify discrepancies, and reflects on the reason for the discrepancies
• Inference

  Speculates, derives, or reasons a specific premise based on information and assumptions obtained from the patient
• Explanation

  Requires that the conclusions drawn from the inferences are cored and can be justified; the use of scientific and nursing literature constitutes the basis for clinical justification
• Evaluation

  Examines the validity of the information and hypothesis; this leads to a final conclusion that can be implemented
• Self-regulation

  Key component to the critical thinking process; the nurse reflects on the critical thinking skills that were employed