Health Assessment

• Nursing process involves ADPIE:

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Nursing emphasizes the "diagnosis and treatment of human responses" based on "accurate client assessments," including the effectiveness of nursing interventions to promote health and prevent illness and injury
• Standard 1 of Nursing Scope and Standards of Practice states, "The registered nurse collects comprehensive data pertinent to the patient’s health or situation"
• To accomplish this, the registered nurse:

  • Collects data in a systematic and ongoing process
  • Involves the patient, family, other health care providers, and environment in holistic data collection
  • Prioritizes data collection activities based on the patient’s immediate condition or anticipated needs
• To accomplish this, the registered nurse:

  • Uses appropriate evidence-based assessment techniques and instruments
  • Uses analytical models and problem-solving tools
  • Synthesizes available data, information, and knowledge relevant to the situation to identify patterns and variances
  • Documents relevant data in a retrievable format
• Standard 2 of Nursing Scope and Standards of Practice states, "The registered nurse analyzes the assessment data to determine the diagnoses or issues"
• To accomplish this, the registered nurse:

  • Derives the diagnosis or issues based on assessment data
  • Validates the diagnoses or issues with the client, family, and other healthcare providers when possible and appropriate
  • Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan
• The nurse's role in health assessment includes various settings like forensic nursing, acute care, critical care outreach, ambulatory care, home health, public health, school nursing, and hospice nursing
• In all settings, the nurse increasingly documents and retrieves assessment data through sophisticated computerized information systems
• Nursing health assessment courses with informatics content are becoming the norm in baccalaureate programs
• Assessment is the first and most critical phase of the nursing process, preceding the other phases and being ongoing and continuous throughout all phases
• Comprehensive health assessment in nursing consists of both a health history and physical examination to collect holistic subjective and objective data to determine a client’s overall level of functioning
• The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client, considering the interdependent factors that affect a person’s level of health
• The nurse assesses how clients interact within their family and community, and how the clients’ health status affects the family and community
• Types of health assessment include initial comprehensive assessment, ongoing or partial assessment, focused or problem-oriented assessment, and emergency assessment
• Initial comprehensive assessment involves the collection of subjective and objective data about the client’s health, past history, family history, lifestyle, and health practices, along with a step-by-step physical examination
• Regardless of who collects the data, a total health assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data
• Frequency of comprehensive assessments depends on the client’s age, risk factors, health status, health promotion practices, and lifestyle
• Ongoing or partial assessment occurs after the comprehensive database is established and consists of a mini-overview of the client’s body systems and holistic health patterns to reassess for any changes
• Health assessment involves various types of assessments:

  • Initial assessment: comprehensive and performed when the client first comes to the health care agency
  • Ongoing or partial assessment: usually performed whenever a nurse or another health care professional has an encounter with the client
  • 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
  • Emergency assessment: very rapid assessment performed in life-threatening situations like choking, cardiac arrest, or drowning
• Steps of Health Assessment:

  1. Collection of subjective data
  2. Collection of objective data
  3. Validation of data
  4. Documentation of data
• Preparing for the Assessment:

  • Review client’s medical record (if available)
  • Validate information with the client and be prepared to collect additional data
  • Educate yourself about the client’s diagnoses or tests performed
  • Take a minute to reflect on your own feelings regarding your initial encounter with the client
  • Obtain and organize materials needed for the assessment
• Collecting Subjective Data:

  • Sensations, symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information are elicited and verified only by the client
  • Major areas of subjective data include biographical information, history of present health concern, personal health history, family history, and health and lifestyle practices
• Collecting Objective Data:

  • Examiner directly observes objective data like physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing
  • General observation and physical examination techniques include inspection, palpation, percussion, and auscultation
• Validating Assessment Data:

  • Crucial part of assessment that often occurs along with the collection of subjective and objective data
  • Ensures that the assessment process is not ended before all relevant data have been collected and helps prevent documentation of inaccurate data
• Documenting Data:

  • Important step of assessment that forms the database for the entire nursing process and provides data for all other members of the health care team
  • Thorough and accurate documentation is vital to ensure valid conclusions are made when the data are analyzed in the second step of the nursing process
• Nursing Diagnosis:

  • Analysis of data, the second phase of the nursing process
  • Analyzing and synthesizing data to determine nursing concerns, collaborative concerns, or concerns that need to be referred to another discipline
• Referrals occur when a concern needs to be addressed by another discipline
• Nurses manage collaborative problems by implementing both physician- and nurse-prescribed interventions to reduce further complications
• Referrals occur because nurses assess the “whole” client, often identifying problems that require the assistance of other health care professionals
• Process of Data Analysis:

  1. Identify abnormal data and strengths.
  2. Cluster the data.
  3. Draw inferences and identify problems.
  4. Propose possible nursing diagnoses.
  5. Check for defining characteristics of those diagnoses.
  6. Confirm or rule out nursing diagnoses.
  7. Document conclusions
• Subjective Data includes sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information elicited and verified only by the client
• Interviewing:

  1. Establish rapport and a trusting relationship with the client to elicit accurate & meaningful information
  2. Gather information on the client’s developmental, psychological, physiologic, sociocultural, and spiritual statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths that can be enhanced through nurse–client collaboration
• Preintroductory Phase:

  • Nurse reviews the medical record before meeting with the client
  • To know client’s biographical information and reason for seeking health care and past health history
• Introductory Phase:

  • After introducing himself to the client, the nurse discusses the purpose of the interview, types of questions, reason for taking notes, and ensures confidentiality of patient information
  • Make client comfortable, provide privacy, and establish rapport
• Working Phase:

  • Nurse elicits the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level
  • The nurse listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client
• Summary and Closing Phase:

  • The nurse summarizes information obtained during the working phase and validates problems and goals with the client
  • Identifies and discusses possible plans to resolve the problem
  • Makes sure to ask if anything else concerns the client and if there are any further questions
• Communication During Interview:

  • Nonverbal Communication includes appearance, demeanor, facial expression, attitude, silence, and listening
  • Verbal Communication includes open-ended questions, closed-ended questions, laundry list, rephrasing, well-placed phrases, inferring, and providing information
• Special Considerations During the Interview:

  • Gerontologic Variations in Communication: assess hearing acuity, speak clearly, face the client, establish trust, privacy, and partnership, speak clearly, avoid medical jargon, show respect
  • Cultural Variations in Communication: reluctance to reveal personal information, ability to receive information, disease and illness perception, decision-making
• Collecting subjective data is a key step of nursing health assessment