Lesson 1 Health Assessment

• Concepts of nursing process
• Reasons for performing a health history
• Techniques for communicating effectively during a health history assessment
• Essential steps in a complete health history
• Questions specific to each step of a health history
• Knowing how to complete an accurate assessment can help uncover significant problems and make an appropriate care plan
• Nursing Process:

  • Definition: A systematic, rational method of planning and providing individualized nursing care
  • Purpose: Identify client health status and actual or potential health care problems and needs, establish plans to meet the identifying needs, deliver specific nursing intervention to meet needs
• Characteristics of nursing process:

  • Cyclic and dynamic
  • Client-centered
  • Planned
  • Goal-directed
  • Universally applicable
• Benefits of Nursing Process:

  • Provides an orderly & systematic method for planning & providing care
  • Enhances nursing efficiency by standardizing nursing practice
  • Facilitates documentation of care
  • Provides a unity of language for the nursing profession
  • Stresses the independent function of nurses
  • Increases care quality through the use of deliberate actions
• The Nursing Process consists of five components or phases:

  1. Assessing
  2. Diagnosis
  3. Planning
  4. Implementing
  5. Evaluating
• Assessment:

  • Assessing is a systematic and continuous collection, organization, validation, and documentation of data
  • Nursing assessment focuses on the client's responses to a health problem
  • Data collection involves four closely related activities: Collecting data, Organizing data, Validating data, Documenting data
• Types of data:

  • Subjective data (symptoms): described or verified only by the person
  • Objective data (signs): obtained through observation and are verifiable
  • Sources of data: client, health care professionals, support people, client records
• Data collection methods:

  • Observing: gather data using the five senses
  • Interviewing: create a comfortable environment, establish rapport, explain what will be covered
• Create the proper environment:

  1. Settling in: choose a quiet, private, well-lit interview setting, ensure patient comfort, explain the purpose of the health history and assessment, reassure confidentiality, inform about the interview duration

  2. Watch what you say: assess for language barriers, speak slowly and clearly, address the patient formally

  3. Communicate Effectively: be aware of nonverbal and verbal communication strategies
• Nonverbal communication strategies:

  • Listen attentively and make eye contact frequently
  • Use reassuring gestures
  • Watch for nonverbal cues of discomfort
  • Be aware of your nonverbal behaviors
  • Observe the patient closely to ensure understanding
• Verbal communication strategies:

  • Range from open-ended to closed-ended questions
  • Techniques include Silence, Facilitation, Confirmation, Reflection, Clarification, Summary, Conclusion
• Reviewing General Health:

  • Biographic data
  • Chief complaint
  • Medical history
  • Family history
  • Psychosocial history
  • Activities of daily living
• Chief Complaint:

  • Try to pinpoint why the patient is seeking health care
• Medical History:

  • Ask about past and current medical problems like hypertension, diabetes, and back pain
• Family History:

  • Question the patient about family health to uncover risk of certain illnesses
• Psychosocial History:

  • Understand how the patient feels about himself, his place in society, and his relationships with others
• Activities of daily living:

  • Includes diet, elimination, exercise, sleep, work, leisure, substance use, and religious observances
• Nursing Diagnosis:

  • Clinical judgment about individual, family, or community responses to health problems/life processes
  • Types: Actual diagnosis (present at assessment) and Risk nursing diagnosis (risk factors indicate a problem may develop)
• Components of NANDA nursing diagnosis:

  • Basic two or three-part statement: Problem (diagnostic label)
• • Disturbed body image R/T amputation AEB patient's verbalization
  • Risk for electrolyte imbalance R/T purging
• Nursing Diagnosis:

  • Basic two or three-part statement:
  • Problem: words added to some NANDA label for additional meaning
  • Etiology: identifies probable causes of the health problem
  • Defining characteristics: cluster of sign and symptoms indicating a specific diagnostic label
  • Nursing Diagnosis process:
  • Analyzing data
  • Identifying health problems, risks, and strengths
  • Formulating diagnostic statement
  • Example of Nursing Diagnosis:
  • Ineffective breathing pattern R/T decreased lung expansion AEB dyspnea
• • Decision Making, Readiness for Enhanced
  • Denial, Ineffective
  • Dentition, Impaired
  • Development: Delayed, Risk for
  • Diarrhea
  • Disuse Syndrome, Risk for
  • Diversional Activity, Deficient
  • Energy Field, Disturbed
  • Environmental Interpretation Syndrome, Impaired
  • Failure to Thrive, Adult
  • Falls, Risk for
  • Family Processes, Dysfunctional: Alcoholism
  • Family Processes, Interrupted
  • Family Processes, Readiness for Enhanced
  • Fatigue
  • Fear
  • Fluid Balance, Readiness for Enhanced
  • Fluid Volume, Deficient
  • Fluid Volume, Deficient, Risk for
  • Fluid Volume, Excess
• List of Nursing Diagnoses:

  • Activity Intolerance, Risk for
  • Airway Clearance, Ineffective
  • Anxiety, Death
  • Aspiration, Risk for
  • Attachment, Parent/Infant/Child, Risk for
  • Impaired Autonomic Dysreflexia
  • Autonomic Dysreflexia, Risk for
  • Blood Glucose, Risk for Unstable
  • Body Image, Disturbed
  • Body Temperature: Imbalanced, Risk for
  • Bowel Incontinence
  • Breastfeeding, Effective
  • Breastfeeding, Ineffective
  • Breastfeeding, Interrupted
  • Breathing Pattern, Ineffective
  • Cardiac Output, Decreased
  • Caregiver Role Strain
  • Caregiver Role Strain, Risk for
• • Role Conflict, Parental
  • Role Performance, Ineffective
  • Sedentary Lifestyle
  • Self-Care, Readiness for Enhanced
  • Self-Care Deficit: Bathing/Hygiene
  • Self-Care Deficit: Dressing/Grooming
  • Self-Care Deficit: Feeding
  • Self-Care Deficit: Toileting
  • Self-Concept, Readiness for Enhanced
  • Self-Esteem, Chronic Low
  • Self-Esteem, Situational Low
  • Self-Esteem, Risk for Situational Low
  • Sexual Dysfunction
  • Sexuality Pattern, Ineffective
  • Skin Integrity, Impaired
  • Skin Integrity, Risk for Impaired
  • Sleep Deprivation
  • Sleep, Readiness for Enhanced
  • Social Interaction, Impaired
• • Thought Processes, Disturbed
  • Tissue Integrity, Impaired
  • Tissue Perfusion, Ineffective (Specify: Cerebral, Cardiopulmonary, Gastrointestinal, Renal)
  • Tissue Perfusion, Ineffective, Peripheral
  • Transfer Ability, Impaired
  • Trauma, Risk for
  • Unilateral Neglect
  • Urinary Elimination, Impaired
  • Urinary Elimination, Readiness for Enhanced
  • Urinary Incontinence, Functional
  • Urinary Retention
  • Ventilatory Weaning Response, Dysfunctional
  • Violence: Other-Directed, Risk for
  • Violence: Self-Directed, Risk for
  • Walking, Impaired
  • Wandering
  • Urinary Incontinence, Overflow
• • Infant Behavior: Organized, Readiness for Enhanced
  • Infant Feeding Pattern, Ineffective
  • Infection, Risk for
  • Injury, Risk for
  • Insomnia
  • Intracranial Adaptive Capacity, Decreased
  • Knowledge, Deficient (Specify)
  • Knowledge (Specify), Readiness for Enhanced
  • Latex Allergy Response
  • Latex Allergy Response, Risk for
  • Liver Function, Impaired, Risk for
  • Loneliness
  • Memory, Impaired
  • Mobility: Bed, Impaired
  • Mobility: Physical, Impaired
  • Mobility: Wheelchair, Impaired
  • Moral Distress
  • Nausea
  • Neurovascular Dysfunction: Peripheral, Risk for
  • Noncompliance (Specify)
• • Nutrition, Imbalanced: Less than Body Requirements
  • Nutrition, Imbalanced: More than Body Requirements
  • Nutrition, Imbalanced: More than Body Requirements, Risk for
  • Nutrition, Readiness for Enhanced
  • Oral Mucous Membrane, Impaired
  • Pain, Acute
  • Pain, Chronic
  • Parenting, Impaired
  • Parenting, Readiness for Enhanced
  • Parenting, Risk for Impaired
  • Perioperative Positioning Injury, Risk for
  • Personal Identity, Disturbed
  • Poisoning, Risk for
  • Post-Trauma Syndrome
  • Post-Trauma Syndrome, Risk for
  • Power, Readiness for Enhanced
  • Powerlessness
  • Powerlessness, Risk for
• • Fluid Volume, Imbalanced, Risk for
  • Gas Exchange, Impaired
  • Grieving
  • Grieving, Complicated
  • Grieving, Risk for Complicated
  • Growth, Disproportionate, Risk for
  • Growth and Development, Delayed
  • Health Behavior, Risk-Prone
  • Health Maintenance, Ineffective
  • Health-Seeking Behaviors (Specify)
  • Home Maintenance, Impaired
  • Hope, Readiness for Enhanced
  • Hopelessness
  • Human Dignity, Risk for Compromised
  • Hyperthermia
  • Hypothermia
  • Immunization Status, Readiness for Enhanced
  • Infant Behavior, Disorganized
  • Infant Behavior: Disorganized, Risk for
• • Urinary Incontinence, Reflex
  • Urinary Incontinence, Stress
  • Urinary Incontinence, Total
  • Urinary Incontinence, Urge
  • Urinary Incontinence, Risk for Urge
• • Comfort, Readiness for Enhanced
  • Communication: Impaired, Verbal
  • Communication, Readiness for Enhanced
  • Confusion, Acute
  • Confusion, Acute, Risk for
  • Confusion, Chronic
  • Constipation
  • Constipation, Perceived
  • Constipation, Risk for
  • Contamination
  • Contamination, Risk for
  • Coping: Community, Ineffective
  • Coping: Community, Readiness for Enhanced
  • Coping, Defensive
  • Coping: Family, Compromised
  • Coping: Family, Disabled
  • Coping: Family, Readiness for Enhanced
  • Coping (Individual), Readiness for Enhanced
  • Coping, Ineffective
  • Decisional Conflict
• • Social Isolation
  • Spiritual Distress
  • Spiritual Distress, Risk for
  • Spiritual Well-Being, Readiness for Enhanced
  • Spontaneous Ventilation, Impaired
  • Stress, Overload
  • Sudden Infant Death Syndrome, Risk for
  • Suffocation, Risk for
  • Suicide, Risk for
  • Surgical Recovery, Delayed
  • Swallowing, Impaired
  • Therapeutic Regimen Management: Community, Ineffective
  • Therapeutic Regimen Management, Effective
  • Therapeutic Regimen Management: Family, Ineffective
  • Therapeutic Regimen Management, Ineffective
  • Therapeutic Regimen Management, Readiness for Enhanced
  • Thermoregulation, Ineffective
• Planning:

  • Types of planning:
  • Initial planning: developed during admission assessment
  • Ongoing planning:
  • Done by all nurses working with the client
  • Done at the beginning of each shift
  • Discharge planning: anticipates and plans for needs after discharge
  • Planning Process:
  • Setting priorities
  • Establishing client goals/desired outcomes
  • Selecting nursing strategies
  • Writing nursing orders
• Implementing:

  • Selecting nursing interventions and activities to achieve client goals
  • Types of Nursing Interventions:
  • Independent intervention: activities initiated based on nurse's knowledge and skills
  • Dependent intervention: activities carried out under physician orders
  • Collaborative intervention: actions carried out in collaboration with other health team members
• Implementing:

  • Phase where nurse puts nursing care plan into action
  • Process of implementing:
  • Reassessing the client
  • Determining the need for assistance
  • Implementing nursing orders (strategies)
  • Delegating and supervising
  • Communicating the nursing actions
• Evaluating:

  • Planned, ongoing activity to judge or appraise
  • Process of evaluating client responses:
  • Identify desired outcomes
  • Collect data related to desired outcomes
  • Compare data with desired outcomes
  • Relate nursing actions to client goals/desired outcomes
  • Draw conclusions about problem status
  • Modify or terminate the client's care plan as needed