HEALTH ASSESSMENT MIDTERMS

• Nursing


  The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
• The definition of nursing emphasizes that it is a comprehensive and holistic profession that goes beyond just treating illnesses. It encompasses a proactive approach to health promotion, preventative care, and addressing the diverse needs of individuals and communities.
• The standards of professional nursing practice and the scope of nursing practice are derived from this foundational understanding of the profession, guiding nurses in their roles and responsibilities.
• Nursing goals

  • To promote health
  • To prevent illness
  • To treat human responses to health or illness
  • To advocate for individuals, families, communities, and populations
• Nurses

  • Provide direct care to help restore health for ill patients in hospitals, clinics, long-term care facilities, and schools
  • Focus on how diseases affect activity levels and abilities to perform tasks, as well as on how patients cope with their health issues and any related losses of function
  • Often work together with primary care providers on medical diagnoses and collaborative problems
  • Perform independent nursing interventions such as patient teaching, therapeutic communication, and physical procedures
  • Advanced practice nurses may function autonomously and practice independently after licensure
• Nurses as managers of care


  • Constantly making treatment decisions to manage and coordinate care
  • Communicate findings to appropriate people and document data to share information and identify trends
  • Refer patients to other health care providers after appropriate assessment
  • Use interprofessional communication and collaboration (IPC) to improve patient health outcomes
• Nurses as members of a profession


  • Nursing research and evidence-based practice can be traced back to Florence Nightingale in the mid-1800s
  • Perform scholarship and research to provide care based on current evidence
  • Professional nursing practice is grounded in best practice, critical inquiry, and skilled questioning
  • Knowledge of patient care technologies and information systems is essential in the management of care
  • Use systems to influence health care policy, finance, and regulatory agencies
  • Advocate for the patient and the profession, taking responsibility to protect the legal and ethical rights of patients
• Nursing values

  • Respect
  • Unity
  • Diversity
  • Integrity
  • Excellence
• Code of Ethics for Nurses


  Focuses on the conscience of the nurse and respect for the individual, providing direction in the clinical setting
• Provisions in the Code of Ethics

  • The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person
  • The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population
  • The nurse promotes, advocates for, and protects the rights, health, and safety of the patient
  • The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care
• Nursing Process


  • Includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation
  • Used to promote health and prevent illness, to reduce the risk of a disease, to reinforce good habits, and to maintain optimal functioning
• Mrs. Gutierrez, age 52, arrives at the clinic for diabetic teaching. She appears distracted and sad, uninterested in the teaching. She is unable to focus, and, paces back and forth in the clinic, wringing her hands. The nurse suspects that Mrs. Gutierrez is upset by her diagnosis of diabetes.
• As the assessment progresses, the nurse learns through the interview with Mrs. Gutierrez that she has no appetite and no energy.
• She feels as though she wants to stay in bed all day. She misses her sisters in Mexico, and cannot do her normal housekeeping or cooking.
• The nurse thinks that Mrs. Gutierrez is probably suffering from depression. But when the nurse asks Mrs. Gutierrez what she believes is causing her lack of appetite and low energy, Mrs. Gutierrez says she was shocked when her husband was hit by a car. He could not work for a month.
• The nurse continues to listen to Mrs. Gutierrez and learns that she is also suffering from "susto." (sudden fear due to trauma).
• Mrs. Gutierrez states that a few days in bed will help her recover her soul and her health.
• The nurse decides to reschedule the diabetic teaching for a later time and provide only essential information to Mrs. Gutierrez at this visit.
• Professional nurses


  Always engaged constantly in observing their surroundings and collecting information to make nursing judgments
• Health assessment


  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
• A health assessment includes both a health history and a physical assessment.
• Informal assessments


  Nurses conduct numerous informal assessments in their daily lives. These assessments are not limited to the clinical environment but extend to personal activities and decision-making.
• Informal assessments


  • Assessing hunger to decide on the type of breakfast needed and evaluating the condition of the skin to determine if moisturizing lotion is necessary.
• The informal assessments nurses make every day help them make informed decisions about how to proceed with their day in terms of comfort and success.
• Informal assessments


  • Before heading out, you might check the weather. If it's sunny, you'll likely choose light clothing; if it's rainy, you might opt for an umbrella or raincoat. This informal assessment helps you prepare for the day's weather conditions.
• The skills used in informal assessments in your personal life, like checking the weather, assessing your hunger, or noting the condition of your skin, are closely related to the formal nursing assessments conducted by professionals.
• In the nursing profession, formal assessments involve systematically collecting data about a patient, family, or community to understand their health needs.
• When nurses conduct formal assessments, they use structured methods to gather comprehensive information.
• Nursing intervention


  Actions or strategies designed to address identified health needs or issues
• Nursing interventions


  • Administering medications
  • Providing education
  • Assisting with activities of daily living
  • Implementing therapeutic interventions
• Direct interventions


  Hands-on actions, such as administering medication or performing a medical procedure
• Indirect interventions


  Health education, counseling, or coordinating social support services
• Nursing interventions are aimed at improving health outcomes, managing illnesses, preventing complications, and promoting overall well-being.
• Nursing is defined 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."
• A key aspect of nursing is the collection of comprehensive data relevant to a patient's health or situation. This involves a systematic and ongoing process of gathering information.
• Nursing: Scope and Standards of Practice states as Standard 1 that "The registered nurse collects comprehensive data pertinent to the patient's health or situation".
• To accomplish this pertinent and comprehensive data collection, the nurse:

  • Collects data in a systematic and ongoing process
  • Holistic data collection
  • Prioritizes data collection activities based on the patient's immediate condition, or anticipated needs of the patient or situation
  • Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data
  • 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 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 health care providers when possible and appropriate
  • Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan
• Physical assessment has been an integral part of nursing since the days of Florence Nightingale.