Health Assessment

• Nursing health assessment


  Differs in purpose, framework, and the end result from all types of professional health care assessment
• Assessment is the first and most critical step of the nursing process, and the accuracy of assessment data affects all other phases of the nursing process
• Key considerations for pertinent and comprehensive data collection

  • Collection of data in a systematic and ongoing process
  • Involves the patient, family, other health care providers, and environment as appropriate in holistic data collection
  • Prioritization of data collection activities based on the patient's immediate condition, or anticipated needs of the patient, or situation
  • Appropriate evidence-based assessment techniques and instruments collecting pertinent data
  • Analytical models and problem-solving tools usage
  • Synthesize available data, information, and knowledge relevant to the situation to identify patterns and variances
• Focus of health assessment

  Collection of holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment
• Mind, body, and spirit are considered to be interdependent factors that affect a person's level of health, focusing on how a client's health status affects the activities of daily living (ADL) and how those ADL affect the client's health
• Assessing how clients interact within their family and community, and how the client's health status affects the family and the community
• Assessing how family and community affect the individual client's health status
• In contrast, the physician performing a medical assessment focuses primarily on the client's physiologic status, less focus may be placed on psychological, sociocultural, or spiritual well-being
• Nursing framework


  Helps to organize information and promotes the collection of holistic data which provides clues that help to determine human responses
• The end result of a nursing assessment is the formulation of nursing diagnoses that require nursing care, identification of collaborative problems requiring interdisciplinary care, identification of medical problems requiring immediate referral, and client teaching for health promotion
• Health Belief Model


  Based on three concepts: 1) Existence of sufficient motivation, 2) Belief that one is susceptible, 3) Belief that changes following a health recommendation would be beneficial to the individual at a level of acceptable cost
• Health Promotion Model


  1. Individual characteristics and experiences, 2) Behavior-specific cognition and affect, 3) Behavioral outcomes
• Model proposes that each person has unique characteristics and experiences that affect the subsequent actions
• Factors affecting health assessment

  • Culture
  • Family
  • Community
  • Spirituality
• Healthcare providers must be aware of any perceived notions they have about the client's culture, family, spirituality, community, and family context
• Focus should include the emphasis on the need to consider the client in the context of best practice in health assessment
• Phases of the nursing process

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Assessment


  Subjective and Objective data collection
• Diagnosis


  Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)
• Nursing diagnosis refers to the clinical judgment concerning a human response to health conditions or life processes, or a vulnerability for that response, by an individual, family, group, or community
• Nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
• Collaborative problems refer to certain physiological complications that nurses monitor to detect their onset or changes in status
• Referrals occur since nurses assess the "whole" client often identifying problems that require the assistance of other health care professionals
• Planning


  Determining the outcome criteria and developing a plan
• Implementation


  Carrying out the plan
• Evaluation


  Assessing whether the outcome criteria have been met and revisiting the plan as necessary
• Types of assessment


  • Initial Comprehensive Assessment
  • Ongoing Comprehensive Assessment
  • Focused Assessment
  • Emergency Assessment
• Initial Comprehensive Assessment


  Involves the collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathering during a step-by-step physical examination
• Assessment frequency considerations


  • Age
  • Risk factors
  • Health status
  • Health promotion practices
  • Lifestyle
• Ongoing / Partial Comprehensive Assessment


  Occurs after the comprehensive database is established, consisting minor overview of the client's body systems and holistic health patterns as a follow-up on health status
• Any problems that were initially detected in the client's body systems or holistic health patterns are reassessed to determine any changes in terms of deterioration or improvement from the baseline data
• Focused / Problem-Oriented Assessment


  Performed when a comprehensive database exists for a client who comes to the healthcare agency with specific health concerns. This type of assessment consists of a thorough assessment of a particular client's problem and does not address areas not related to the problem
• This type of assessment does not replace the comprehensive health assessment
• Emergency Assessment


  Rapid assessment performed in life-threatening situations as an immediate assessment is needed to provide prompt treatment
• The major and only concern during this type of assessment is to determine the status of the client's life-sustaining physical functions
• Steps of health assessment

  • Subjective data collection
  • Objective data collection
  • Data validation
  • Data documentation
• Initial preparatory steps


  • Review the client's record
  • Review the client's status with other healthcare team members
  • Educate about the client's diagnosis and tests performed
• Subjective data collection


  Data referring to sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• Major areas of subjective data

  • Biographical information
  • History of present health concern
  • Personal health history
  • Family history
  • Health and lifestyle practices
  • Review of systems
• Objective data collection


  Data obtained by general observation and by using the four (4) physical examination techniques: inspection, palpation, percussion, and auscultation