HEALTH ASSESSMENT

• Health assessment


  A deliberate problem-solving approach for meeting people's health care and nursing needs
• Nursing process


  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

  
• Characteristics of nursing process


  • Client-centered
  • Adapted of problem-solving technique
  • Planned
  • Cyclic and dynamic

  
• Assessment


  Systematic collection of data through interview, observation, and examination to determine the patient's health status as well as any actual or potential health problems
• Types of assessment


  • Database assessment
  • Focus assessment
  • Emergency assessment
  • Ongoing assessment
• Data collection


  The process of gathering information about client health status
• Characteristics of data


  • Complete
  • Accurate
  • Relevant
• Sources of data


  • Primary source: Client
  • Secondary source: Client's family, reports, test results, information in current and past medical records
• Types of data


  • Subjective data (symptoms, covert data)
  • Objective data (signs or overt data)
• Methods of data collection

  • Observation
  • Interview
  • Physical examination
  • Laboratory and diagnostic data
• Biographical data


  • Name
  • Age
  • Gender
  • Marital status
  • Educational level
  • Occupation
  • Religion
  • Birth date
  • Birth place
  • Phone number
  • Phone number of significant person
  • Address
• Past history


  • Previous Illness or Diseases
  • Previous Surgery
  • Allergies
  • Accident and injury
  • Immunization
  • Medication
  • Previous hospitalization
• Present history (pain assessment)

  • Characteristics
  • Onset
  • Location + Radiation
  • Duration
  • Severity
  • Pattern
  • Association sign and symptom
• Social History


  • Alcohol Use
  • Tobacco Use
  • Drug Use
  • Sleep
  • Diet
  • Exercise
  • Stress
  • Stress Management
  • Economic Status
  • Hobbies and Leisure Activities
  • Roles and Relationship
  • Characteristic Patterns of Daily Living
• Daily activities


  • Bathing
  • Dressing
  • Eating
  • Toileting
  • Grooming
  • Drinking
  • Ambulating
• Nursing diagnosis


  A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes that can be managed by independent nursing interventions

  
• Types of nursing diagnoses

  • Actual: A problem exists
  • Risk: A problem does not yet exist
• Planning


  • Prioritize problem
  • Formulate goal
  • Select nursing intervention
  • Write nursing order
  • Record and modify

  
• Goals


  • Short-Term Goals
  • Long-Term Goals
• Components of outcomes


  • Subject
  • Verb
  • Condition
  • Performance criteria
  • Target time
• Interventions


  • Independent (Nurse initiated)
  • Dependent (Physician initiated)
  • Collaborative
• Implementation


  1. Reassessing the client

  2. Determine the nurse need for assistance

  3. Implementing

  4. Supervising

  5. Document the action
• Evaluation


  • A comparison of client behavior and/or response to the established outcome criteria
  • Continuous review of the nursing care plan
  • Examines if nursing interventions are working
  • Determines changes needed to help client reach stated goals