HEALTH ASSESSMENT APPLE

• Nursing Process (ADPIE)


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation
• Assessment


  • Involves discovery, decision making, critical thinking skills, and data collection
  • Supplement, confirm or refute data obtained from history
  • Confirm or identify nursing diagnosis
  • Make judgements about health status and management
  • Evaluate outcomes
• Data gathered in assessment

  • Client history
  • Family history
  • Living situation
• Types of assessment


  • Interview
  • Primary assessment
  • Focused assessment
  • Head-to-toe
• Objective data


  Measurable, verifiable facts
• Subjective data


  Observations, perceptions
• Data sources


  • Primary: Client, Family, Physician, Allied Health
  • Secondary: Chart, Nurse experience
  • Tertiary: Literature
• Primary (ABCDE) assessment


  1. The first assessment you will do when you meet your client

  2. Repeated whenever you suspect or recognize that your client's status has become, or is becoming, unstable
• Safety considerations


  • PCRA - environment, patient, nurse, task
  • Infection Control Practices
  • Falls Prevention
  • UBC scope of practice
  • BCCNM
• Skills of Physical Assessment: Inspection


  1. Visual check

  2. Position and expose body parts so all surfaces can be viewed

  3. Inspect for size, shape, colour, symmetry, position, drainage, & abnormalities

  4. Compare one side with the other side (right hand & left hand)
• Skills of Physical Assessment: Auscultation


  1. Use of a stethoscope

  2. Familiarity with normal sounds first before identifying abnormal sounds or variations

  3. Characteristics of sounds: frequency, loudness, quality, duration

  4. Requires concentration & practice
• Skills of Physical Assessment: Palpation


  1. Touch

  2. Assesses for tenderness, distension, masses

  3. The nurse uses different parts of hands to distinguish texture, temperature, and movement

  4. Light palpation is generally enough

  5. Tender areas are palpated last
• Skills of Physical Assessment: Percussion

  1. Client's body is tapped with fingertips to produce a vibration

  2. Sound indicates location, size, and density of structures

  3. Used primarily by nurse practitioners & physicians in practice
• Considerations with Older People


  • Communication techniques
  • Keep them warm
  • Adjust as necessary
  • Utilize knowledge of normal changes of ageing vs misconceptions
  • Utilize knowledge of atypical presentations of illness
  • Utilize knowledge of increased risks associated with infection and safety
  • May take longer
  • May need rest periods
  • Signs and symptoms may differ
• Diagnosis


  1. Analyze data collected in the assessment

  2. Identify health problems, risks & strengths

  3. Formulate diagnostic statements and identify client needs
• Nursing diagnosis


  A clinical judgment about client responses to an actual or potential health problem
• Medical diagnosis


  The identification of a disease or condition on the basis of specific evaluation of signs and symptoms
• Collaborative family


  An actual or potential complication that nurses monitor to detect a change in client status
• Planning


  1. Set priorities

  2. Establish client-centered goals/outcomes

  3. Select nursing interventions

  4. Write a plan of care (PoC)
• Implementation


  1. Carrying out or delegating nursing interventions

  2. Promote health

  3. Prevent complications

  4. Treat symptoms

  5. Facilitate coping
• Nursing interventions


  • Ensure client is cleared from confusion
  • Ensure medications given as ordered
  • Ensure appropriate mobility TID, up for meals. Follow PT and OT direction
• Evaluation


  1. Avoid errors by developing critical thinking

  2. Think about which is priority (high urgency and low urgency)
• What is documented


  • Assessment findings
  • Diagnosis
  • Implementation of interventions
  • Evaluation
• Charting methods


  • 24 hour flow sheet
  • Narrative Nursing Notes
  • Charting By Exception
  • DAR – Data (assessment data), Action (nursing intervention), Response (Evaluation)
  • Nursing Care Plans
  • Graphic Sheets (vital signs)
  • Medication Administration Records (MARs)
• Anything heard, seen, felt, or smelled should be reported accurately
• Be objective and avoid adding in your personal judgements
• Subjective client information should be placed in quotation marks
• Accurate terminology and abbreviations must be used, only approved abbreviations should be used