HA MIDTERMS

• Nurse's Role in Health Assessment

  Collecting and Analyzing Data
• Definition of Nursing (ANA)

  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
• Pertinent and comprehensive data collection, the nurse:


  1. Collects data systematically

  2. Involves patient, family, other health care providers, and environment

  3. Prioritizes data collection based on the patient's immediate condition

  4. Uses 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
• Phases of the Nursing Process

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
• Assessment: Step 1 of the Nursing Process

  Analyzing and synthesizing data
• Types of health assessment

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


  1. Collection of subjective data

  2. Collection of objective data

  3. Validation of data

  4. Documentation of data
• Preparation before assessment


  1. Review client's medical record

  2. Discuss client's status with others

  3. Educate self about the client's status

  4. Reflect on your own feelings

  5. Obtain and organize materials needed
• Subjective data


  Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be 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
  • Environment
• Objective data


  Directly observed by the examiner
• Types of objective data

  • Physical characteristics
  • Body functions
  • Appearance
  • Behavior
  • Measurements
• Methods used to obtain objective data

  1. Inspection

  2. Palpation

  3. Percussion

  4. Auscultation
• Other sources of objective data


  • Client's medical record
  • Observations noted by the family or significant others
• Comparing subjective and objective data

  Subjective data: Data elicited and verified by the client

  Objective data: Observations and physical assessment findings of the nurse or other health care professionals
• Validating assessment data


  Ensures the assessment process is not ended before all relevant data have been collected

  Helps to prevent documentation of inaccurate data
• General Information


  • Patient's Name
  • Occupation
  • Address
  • Age
  • Status
  • Sex
  • Religion
  • Date & Time Admitted
  • Chief Complaints
• Present Illness


  • Reason why the patient was admitted
  • Chief complaints
• Previous Illness


  • Any previous illnesses or hospitalizations
  • Cause
  • What experience have you had in hospital before
• Reactions to and Expectations about Hospitalization


  • Meaning of Illness to patient, families and relatives, SO
  • Understanding regarding nature of illness, of care
  • Feelings about hospitalization
  • What effect do you expect this illness will have on your life?
  • Do you expect any change in ability to function as a man? Father? Husband? Woman? Wife? Mother?
  • Reactions to alterations in body image
  • Position or dependency scale
  • Reactions to separation from his usual life situations
• Reactions about Treatment and Diagnostic Procedures


  • Expectations about diagnostic test, diet, medications, other therapy, rehabilitation programs
  • What would you like to know about test and treatment planned?
  • What would you like to know about the results of test and treatment?
  • Attitudes towards body exposure for examination and treatment
  • What did you like about the nursing care? (modesty)
  • Dislike
• Other Sources


  • Laboratory Exam
  • Result
• Nursing History


  Normal Patterns of Functioning (Before Admission)
• Patterns of Functioning


  • Respiration
  • Circulation
  • Food and Fluid Intake
  • Elimination
  • Rest and Sleep
  • Exercise
  • Pain/Discomfort
• Religious Life


  • Usual pattern of worship, church attendance?
  • Active/passive participants
  • Type of personal devotions, religious literature read
  • Wish clergyman to visit? Who?
  • Religious belief and practices regarding diet, days of worship, holy days, birth, blood transfusion, use of rigs
• Social/Occupational Life


  • Work role type and hours of work
  • Feelings regarding work
  • Family roles
  • Members of households
  • Social roles-kinds of social activities of interest
  • Will family and friends be able to visit?
  • Any especially want to see? Not want to see?
  • Cultural prescriptions regarding health care and practices
• Recreation/Diversion


  • What done for fun? Hobby? Vacation?
  • What pass time done while ill?
  • Have interest you would like to pursue but never had the time?
  • Child's favored play activities and playthings
• Health Supervision


  • When physicians prescribe a special diet, medication or program, how closely do you follow it?
  • What kinds of illness send you to bed?
  • What reasons do you stay off work?
  • What for reasons do you consult a doctor? Dentist?
  • Whose help do you seek first you used in the past? For what purpose?
  • Keep appointment? Yearly examination?
  • What examinations have you had? When?
  • Who can help with your care when you return home?
• Regulatory Mechanism


  • Chills? Fever? Perspire profusely?
  • Tolerance of heat? Cold?
  • Fainting? Dizzy spells? Seizures?
  • Menstruation when due? Supplies needed?
  • Menopause? Hot flashes?
  • Hormone replacement therapy?
  • Birth control pills?
  • Onset of contraception
  • When baby is due?
  • Have membrane nuptured?
• Personal Hygiene


  • Amount and appearance of lochia
  • Breast engorgement, tenderness, state of nipples
  • Appearance of perineal area
  • Ability for self-care
  • Kind, time, frequency of bath, shampoo?
  • Oral hygiene time? Frequency?
  • Preferred dentifrice? Mouthwash?
  • Denture care?
  • Nail, cutical problem?
  • What done for any skin conditions?
  • Frequency and time of shaving?
• Communication and Special Senses

  • Any difficulty speaking, hearing, seeing, understanding?
  • English? Read? write?
  • What done to keep in touch with family, friends, businesses?
  • What name does child or adolescent prefer?
• Coping with Stress


  • What done when facing stressful situations
  • What do you do when you are upset? Angry? Frightened?
• Competencies


  • Physical
  • Mental
  • Emotional
  • Spiritual
  • Environmental