HEALTH ASSESSMENT

• NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND ANALYZING DATA
• Standard I

  1. Collects comprehensive data pertinent to the patient’s health or situation

  2. Involves the patient, family, and other health care providers, and environment in holistic data collection

  3. Prioritizes data collection activities based on the patient’s immediate condition or anticipated needs

  4. Uses appropriate evidence-based assessment techniques and instruments

  5. Uses analytical models and problem-solving tools

  6. Synthesizes available data, information, and knowledge relevant to the situation

  7. Documents relevant data in a retrievable format
• PENDER’S HEALTH PROMOTION
• NURSING PROCESS: The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps: Assessment, Diagnosis, Planning, Implementation, Evaluation.
• Phases of Nursing Process: Implementation

  1. Nurse-initiated treatments

  2. Physician-initiated treatments
• Phases of Nursing Process: Diagnosis

  1. Data analysis

  2. Problem Identification

  3. Label
• EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT: Physical assessment is an integral part of nursing. Nurses relied on natural senses, palpation, and movement of healthcare from acute care to baccalaureate and education. Advanced practice nurses have evolved.
• FOCUS OF HEALTH ASSESSMENT IN NURSING: The purpose is to collect holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. Holistic data collection includes physiological, sociocultural, developmental, and spiritual aspects. Interdependent factors that affect a person’s level of health include mind, body, and spirit.
• NURSING: SCOPE AND STANDARDS OF PRACTICE

  • Standard I
  • Standard 2
• Phases of Nursing Process: Planning

  1. Priorities

  2. Outcomes

  3. Interventions
• FACTORS FOR ADVANCED ASSESSMENT SKILLS IN NURSING

  • Rising educational costs and increased focus on primary care
  • Increasing complexity of acute care
  • Growing aging population with complex comorbidities
  • Expanding health care needs of single parents
  • Increasing impact of children and the homeless on communities
  • Intensifying mental health issues
  • Expanding health service networks
  • Increasing reimbursement for health promotion and preventive care services
  • Limited number of medical students pursuing practice in primary care settings
  • Aging of the baby boomer generation
• Emphasis on nursing


  • Placed on “diagnosis and treatment of human responses” based on “accurate client assessments”, including how effective nursing interventions are “to promote health and prevent illness and injury”
• FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING

  1. Helps to organize information and promotes the collection of holistic data

  2. Four (4) sections in health assessment: History of present health concerns, Personal health history, Family History, Lifestyle and health practices
• Standard 2

  1. Analyses the assessment data to determine the diagnoses or issues

  2. Derives the diagnosis or issues based on assessment data

  3. Validates the diagnoses or issues with the client, family, and other health care providers

  4. Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan
• Introduction: American Nurses Association (ANA) defines nursing as “the protection, promotion, and optimization of health and abilities/ prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities, and populations.”
• Phases of Nursing Process: Assessment

  1. Subjective data

  2. Objective data
• Phases of Nursing Process: Evaluation

  1. Data

  2. Diagnosis

  3. Etiologies

  4. Plans

  5. Interventions
• Nursing framework

  Helps to organize information and promotes the collection of holistic data
• Nursing Diagnosis is often called data analysis and involves determining whether the data reveal a nursing concern, a collaborative concern, or a concern that needs to be referred to another discipline
• Types of health assessment

  • Initial comprehensive assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency assessment
• Emergency Assessment

  A very rapid assessment performed in life-threatening situations to determine the status of the client's life-sustaining physical functions
• Objective Data

  Physical characteristics, body functions, appearance, behavior, measurements, laboratory test results
• Pender’s Health Promotion

  • Individual Characteristics and Experiences
  • Behavior-Specific Cognitions and Affect
  • Behavioral Outcomes
• Ongoing or Partial Assessment

  Data collection that occurs after the comprehensive database is established, providing a mini overview of the client's body systems and holistic health patterns
• Focused or Problem-Oriented Assessment

  Does not replace the comprehensive health assessment, involves a thorough assessment of the client's health problem including physical examination
• Factors influencing health promotion

  • Prior related behavior
  • Personal factors: Biological, psychological, sociocultural
  • Perceived benefits of activities
  • Perceived barriers to actions
  • Immediate competing demands (low control) and preferences (high control)
  • Perceived self-efficacy
  • Activity-related affect
  • Interpersonal influences: family, peers, providers; norms, support, models
  • Situational influences: options, demands, characteristics, aesthetics
  • Commitment to a plan of action
  • Health promoting behavior
• Major Areas of Subjective Data

  • Biographical information
  • History of present health concerns
  • Personal health history
  • Family history
  • Health and lifestyle practices
  • Review of systems
• Initial Comprehensive Assessment

  Involves collection of subjective data about the client's perception of health, past health history, family history, lifestyle, and health practices
• Sections in health assessment

  • History of present health concerns
  • Personal health history
  • Family History
  • Lifestyle and health practices
• Steps of Health Assessment

  1. Collection of subjective data

  2. Collection of objective data

  3. Validation of data

  4. Documentation of data
• 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