Health Assessment ( Nursing Process )

• Nursing process is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
• Purposes of nursing process:

  • Identify a client's health status and actual and potential health care problems or needs
  • Establish plans to meet the identified needs
  • Deliver specific nursing interventions to meet those needs
• Components of nursing process:

  • Assessment (data collection)
  • Nursing diagnosis
  • Planning
  • Implementation
  • Evaluation (ADPIE)
• Characteristics of nursing process:

  • Cyclic
  • Dynamic nature
  • Client centeredness
  • Focus on problem solving and decision making
  • Interpersonal and collaborative style
  • Universal applicability
  • Use of critical thinking and clinical reasoning
• Health assessment involves:

  • Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes
  • Tepid Sponge Bath Circular Motion to improve circulation
  • Essential nursing function providing foundation for quality nursing care and interventions
  • Identifying strengths of clients in promoting health
  • Identifying client's needs and clinical problems
  • Evaluating responses of the person to health problems and interventions
• Nurse and assessment:

  • Accurate and thorough health assessment reflects knowledge and skill
• Assessment is the first step to determine health status, gathering information to have all the necessary puzzle pieces to make a clear picture of the person's health status
• Nursing focuses on client's responses to a health problem, involving client's perceived needs, health proper related experience, health practices values, and lifestyles

  • Data collected should be relevant to a particular health problem
  • Nurses should think critically about what to assess
• Medical assessment vs nursing assessment:

  • Medical assessment focuses on diagnosis and treatment
  • Nursing assessment focuses on the patient as a person and reaching the optimal level of wellness (holistic approach)
  • Both should complement each other, not contradict
  • Nursing assessment contributes to the identification of medical problems
• Health assessment components:

  • Nursing health history
  • Physical assessment
  • Records and reports
  • Review of laboratory and diagnostic test results
• Types of assessment:

  • Initial comprehensive assessment
  • Ongoing/partial assessment
  • Focused assessment/problem-oriented assessment
  • Emergency assessment
• Emergency assessment involves using triage to determine the level of activity based on A,B,C,D:

  • A - Airway
  • B - Breathing
  • C - Circulation
  • D - Disability (LOC, pupils, movement)
• Cultural competence:

  • Culture is defined as the traits that a group of people names and passes from generation to the other, including values, beliefs, attitude, and customs
  • Assessment for the effects of spirituality and religion in health is also important
• Collection of data:

  • Observation using the senses
  • Interview planned
  • Examination
• 2 approaches to interviewing:

  • Direct - highly structured and directly ask questions
  • Nondirective - rapport building interview
• Methods of data collection:

  • Observation
  • Interview
  • Examination
• Phases of interview process:

  • Pre-interaction phase
  • Beginning phase
  • Working phase
  • Closing phase