HEALTH ASSESSMENT

• HEALTH ASSESSMENT


  gathering information about the health status of the client
• HEALTH ASSESSMENT


  analyzing and synthesizing that data, making judgments about the effectiveness of nursing interventions, and evaluating client care outcomes
• ASSESSMENT


  first and most critical phase of the nursing process
• PURPOSE OF NURSING HEALTH ASSESSMENT


  to collect holistic subjective and objective data to determine a client’s

  overall level of functioning in order to make a professional clinical judgment
• INITIAL COMPREHENSIVE ASSESSMENT 


  involves a collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination.
• ONGOING OR PARTIAL ASSESSMENT


  consists of data collection that occurs after the comprehensive database is established
• ONGOING OR PARTIAL ASSESSMENT


  consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status
• FOCUSED OR PROBLEM ORIENTED ASSESSMENT


  performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern.
• FOCUSED OR PROBLEM-ORIENTED ASSESSMENT


  consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem.
• EMERGENCY ASSESSMENT


  very rapid assessment performed in life-threatening situations
• SUBJECTIVE DATA


  sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• OBJECTIVE DATA


  obtained by general observation and by using the four physical examination techniques: inspection, palpation, percussion, and auscultation
• VALIDATING ASSESSMENT DATA 


  crucial part of assessment that often occurs along with collection of subjective and objective data.
• VALIDATING ASSESSMENT DATA 


  serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data.
• DOCUMENTING DATA


  forms the database for the entire nursing process and provides data for all other members of the healthcare team.
• BASIC STEPS OF HEALTH ASSESSMENT

  • collection of subjective data
  • collection of objective data
  • validation of data
  • documentation of data
• Patient says his tummy hurts

  Subjective data
• The patient's respiratory rate is 20

  Objective data