INTRODUCTION TO HEALTH ASSESSMENTHealth assessment.docx

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1. INTRODUCTION TO HEALTH ASSESSMENTHealth assessment
 is
the systematic process of gathering and analyzing subjectiveand objective
data
about an individual's health status to identify actual or potential
health problems, establish a baseline for health promotion, and facilitate the 
development of anappropriate
plan of care.
HEALTH ASSESSMENT
“The
very elements of
 nursing
are all but
 unknown”
- FLORENCE
NIGHTINGALE
1859
DEFINITION OF NURSING
 Nursing
is the diagnosis and treatment of human responses to health and
illness
–
 ANA 1995
WHAT IS NURSING?
 Nursing
is both
 a

SCIENCE
and
AN ART that
is
 concerned
with the
individual’s:
1.Physical
2.Psychological
3.Sociological
4.Cultural
5.Spiritual
4 ESSENTIALS FEATURES OF THE NURSING PRACTICE - ANA 1995
1.Full
range of human experiences and responses to health and illness w/o
restriction
toa problem focused orientation (attention)
2.Caring
relationship that facilitates health and healing
3.Understanding
and integration of objective data based on the client’s
subjective
experience
4. Knowledge
(scientific) for diagnosis and treatment
Health Assessment is:
•The
first step of the Nursing Process
•The
most important because it
DIRECTS
the rest of the process
•
A thinking, doing, and feeling process -
THINK as
you
ACT and
interact
with patients
•THINK CRITICALLY
as you go with the process
•
A skill
•LEARNING
the normal
•

IDENTIFY the
normal and
DIFFERENTIATE it
from the abnormal
•Will

USE
n every area of nursing. How well you perform your assessment
will
affect everything else that follows. You will ask questions, and you will
use
four of your senses to collect data.
FUNDAMENTAL PHILOSOPHICAL BELIEFS IN NURSING
1.
The client is a
 human
being who has worth and has
 dignity.
2.
Humans manifest an essential unity of mind/body and spirit.
3.There
are basic human needs that must be met.
4.When
these needs are not met, problems arise that may require
intervention
by another person until the individual can resume
responsibility
for themselves.
5.Human
experience is contextually and culturally defined.
6.Clients
have a right to quality health and nursing care delivered with
interest,
compassion and competence, with a focus on wellness and
prevention.
7.The
therapeutic nurse-client relationship is important in the nursing
process.

2. A.OVERVIEW OF THE NURSING PROCESS WHAT IS THE NURSING
PROCESS?
"Combines
the most desirable elements of the art of nursing with
the
most relevant elements of systems theory, using the scientific
method"
- Shore 1988

"This process incorporates an interactive/interpersonal approach
with
a problem solving and decision-making process" - Peplau 1952
Is
a SYSTEMATIC, organized method of planning, and providing
quality
and individualized nursing care. It is synonymous with the
PROBLEM-SOLVING
APPROACH that directs the nurse and the client
to
determine the need for nursing care, to plan and implement the
care
and evaluate the result IN SHORT THE NURSING PROCESS IS A
SYSTEMATIC
PROBLEM- SOLVING APPROACH
Where
diagnosis and treatment are achieved It is a
GOSH
approach
for
efficient and effective provision of nursing care.
Goal
oriented
Organized

Systematic

Humanistic
care
ASSESSMENT: STEP 1 OF THE NURSING PROCESS
Assessment
is the initial and most crucial phase of the nursing
process.
Inadequate or inaccurate data collection can lead to
incorrect
clinical judgments, impacting subsequent phases:
diagnosis,
planning, implementation, and evaluation.
Nurses'
clinical judgment refers to the comprehensive process of
synthesizing
information, interpreting cues, making decisions, and
taking
appropriate actions in the provision of nursing care. It
involves
critical thinking, reasoning, and the application of nursing
knowledge
and experience to achieve optimal client outcomes.
Assessment
is ongoing and continuous throughout all phases of the
nursing
process.
Health
assessment involves analyzing and synthesizing data, making
judgments
about nursing interventions' effectiveness, and
evaluating
client care outcomes.
The
nursing process is circular, not linear, emphasizing the
interdependence
of its steps.
Evaluation
focuses on achieving desired outcomes and involves
examining
all previous steps.
Assessment
and evaluation are ongoing processes as well as distinct
phases,
with a continuous feedback loop.
If
outcomes are not as anticipated, the nurse must revisit all steps,
collect
new data, and adjust the plan of care accordingly.
PHASES OF THE NURSING PROCESS 5 steps of the Nursing Process
(ADPIE)
1.
ASSESSMENT
2.
DIAGNOSIS
3.
PLANNING
4.
INTERVENTION
5.
EVALUATION
1. ASSESSMENT
Systematic
collection of data.
The
most important step Sets the tone for the rest of the process,
and
the rest of the process flows from it Identifies your patient's
strengths
and limitations and is performed not just once, but
continuously
throughout the nursing process
This
phase involves gathering subjective and objective data about
the
client's health status.

3. Subjective
data are what the client expresses or feels, while
objective
data are observable and measurable.
Example:
A nurse conducts a comprehensive assessment of a
patient
admitted to the hospital with chest pain. The nurse
interviews
the patient to gather subjective data about the onset,
location,
and characteristics of the pain.
Additionally,
the nurse collects objective data by performing a
physical
examination, including vital signs, auscultation of heart and
lung
sounds, and assessment of skin color and temperature.
2. DIAGNOSIS
Clinical
judgment concerning a human response to health conditions
/
life processes, or vulnerability for that response by an individual,
family
or community that the nurse is licensed and competent to
treat
Analysis of data to identify the problem.
Formulating
a nursing diagnosis involves identifying and prioritizing
actual
or potential health problems or responses.
✓
An actual nursing diagnosis identifies an occurring health problem
for
your patient.
✓
A potential nursing diagnosis identifies a high-risk health problem
that
most likely will occur unless preventive measures are taken.
✓
A possible nursing diagnosis is one that needs further data to
support
it Types of Nursing Diagnosis
1.
Problem - focused ND Problem - Etiology + Signs and Symptoms
Acute
pain related to trauma of surgical incision as evidenced by
facial
grimace and guarding behavior
2.
Risk ND . Problem + Etiology Risk for infection related to surgical
incision.

3.
Health Promotion ND Problem Grieving, Hopelessness 4.
Syndrome
ND Specific cluster of nursing diagnosis that occur
together
and have similar nursing interventions to resolve the
situation.
Defining Characteristics (Signs and Symptoms)
✓
Observable assessment cues such as patient behavior, physical
signs
Related Factor (Etiology)
✓
Etiological cause or causative factor for diagnosis In this phase,
the
nurse analyzes the collected data to identify health problems,
risks.
and strengths.
Nursing
diagnoses are clinical judgments about actual or potential
health
problems.
Example:
Based on the assessment findings, the nurse identifies the
nursing
diagnosis of "Acute Pain related to myocardial ischemia" for
the
patient experiencing chest pain.
The
nurse prioritizes this diagnosis due to its significance in the
patient's
current health condition.
3. PLANNING
•Desired
outcomes
•Appropriate
interventions
•Involves
setting goals and outcomes
•Individualized
plan of care for your patient is ready once diagnosis
have
been prioritized
•Priority
Setting ○ Ordering of nursing diagnoses or patient
problems
using notions of urgency and importance to establish a
preferential
order for nursing interventions.

•GOALS.
○
Broad statement that describe a desired change in a patient's
condition
perceptions or behavior

•TYPES OF GOALS.

4. □Long term Goals
•Objective
behavior or response that you expect a patient to
achieve
over a longer period, usually few hours or less than a week.
•Planning
should be (SMART)
○
S-specific
○
M-measurable
○
A-attainable

○ R-realistic
○
T-time bound

During planning, the nurse collaborates with the client, family, and
healthcare
team to develop a comprehensive care plan. This plan
outlines
goals, interventions, and expected outcomes.
Example:
The nurse develops a plan of care for the patient with
chest
pain. Goals may include relieving pain, stabilizing vital signs,
and
preventing complications.

Interventions may include administering pain medications,
monitoring
cardiac status, and providing education on lifestyle
modifications.

4. IMPLEMENTATION/INTERVENTION
Defined
as any treatment based on clinical judgment and knowledge
that
a nurse performs to enhance patient outcomes. Putting the
plan
of care into action.
Also
called IMPLEMENTATION Involves carrying out your plan to
achieve
goals and outcomes The "doing" phase Approach
DIRECT INTERVENTION

Direct intervention Interventions are treatment performed through
interaction
with patient.
Ex.
Medication administration, VS checking, insertion of IFC.
Indirect
Care

Interventions are treatments performed away from a patient but on
behalf
of the patient or group of patient
Ex.
Safety and Infection control, Delegating nursing care Types
•✓
Independent Action that the nurse initiates without supervision
or
direction from others
•✓
Dependent Actions that require an order from a health care
provider

•✓
Collaborative Interdependent interventions Therapies that
require
the combined knowledge, skills, and expertise of multiple
health
care providers Implementation involves carrying out the
planned
interventions to achieve the identified goals.
Nurses
prioritize interventions based on the client's needs and the
urgency
of the situation.
Example:
The nurse implements the plan of care by administering
prescribed
pain medications, monitoring the patient's cardiac status,
and
providing emotional support. Additionally, the nurse ensures
that
the patient follows dietary and activity restrictions.
5. EVALUATION
Final
step of the nursing process crucial to determine if the patient's
condition
improved or worsen after application of the first four steps
of
nursing process
•
Monitoring of client's progress Alter the plan as indicated Involves
determining
the effectiveness of your plan.

Once again, assess your patient's response based on the criteria you
set
for the outcome.
In
this final phase, the nurse evaluates the effectiveness of the
interventions
in achieving the desired outcomes. If outcomes are
not
met, the nurse revises the plan of care accordingly.

5. Example:
The nurse evaluates the patient's response to pain
management
interventions by reassessing the intensity and
frequency
of chest pain. If the pain persists despite medication
administration,
the nurse collaborates with the health care team to
adjust
the treatment plan, such as modifying medication doses or
exploring
alternative pain management strategies.
The
Nurse Must Take Note:
▪
︎The steps of the nursing process are interrelated forming a
continuous
circle of thought and action ▪︎that is both dynamic and
cyclic.

•▪The
nurse must be able to apply some basic abilities on the
knowledge
of science and theory.
▪
︎Creativity and adaptability are very important
CHARACTERISTICS
OF THE NURSING PROCESS
•Dynamic
and cyclic
•Patient
centered
•Goal
directed
•Flexible

•Problem
oriented
•Cognitive

•Action
oriented
•Interpersonal

•Holistic

•Systematic
PURPOSES OF THE NURSING PROCESS
1.
To identify a client's health status; his Actual/Present and
potential/possible
health problems or needs.
2.
To establish a plan of care to meet identified needs.
3.
To provide nursing interventions to meet those needs.
4.
To provide an individualized, holistic, effective and efficient
nursing
care.
B. HEALTH ASSESSMENT IN NURSING PRACTICE FOCUS OF HEALTH
ASSESSMENT IN NURSING
The
focus of health assessment in nursing is to gather
comprehensive
subjective and objective data to evaluate a client's
overall
health status and identify any actual or potential health
problems.

This assessment encompasses various dimensions of health,
including physical, psychological, sociocultural, developmental,
and spiritual aspects.
1.Physiological Aspect:
This aspect focuses on the client's physical
health,
including body systems, vital signs, and any physical
symptoms
or conditions.
Example:
The nurse assesses the client's vital signs (e.g.,
temperature,
blood pressure, heart rate, respiratory rate) and
performs
a physical examination to identify any abnormalities or
signs
of illness.
2. Psychological Aspect:
This aspect considers the client's mental
and
emotional well-being, including cognitive function, mood,
coping
mechanisms, and stress levels.
Example:
The nurse assesses the client's mental status, asking
questions
to evaluate cognitive function and observing for signs of
anxiety,
depression, or other psychological distress.

6. 3. Sociocultural Aspect:
This aspect examines the client's social and
cultural
background, beliefs, values, customs, family dynamics, and
support
systems.
Example:
The nurse explores the client's cultural beliefs regarding
health
and illness, dietary preferences, religious practices, and
family
roles to understand how these factors influence their health
behaviors
and decision-making.
4. Developmental Aspect:
This aspect considers the client's stage of
development
across the lifespan, including growth and maturation,
developmental
milestones, and age-specific health considerations.
Example:
For pediatric clients, the nurse assesses developmental
milestones,
growth parameters, and age-appropriate behaviors. For
elderly
clients, the nurse evaluates factors such as mobility, sensory
changes,
and cognitive decline.
5. Spiritual Aspect:
This aspect focuses on the client's spiritual
beliefs,
values, faith, sources of meaning, and existential concerns.
Example:
The nurse engages in therapeutic communication to
explore
the client's spiritual beliefs, providing opportunities for
prayer,
meditation, or connection with a spiritual leader if desired.
The
nurse also supports the client in finding meaning and purpose in
their
health journey. By conducting a holistic health assessment,
nurses
aim to understand the client's unique health needs,
strengths,
and challenges, which guides them in providing
individualized
and culturally sensitive care. The ultimate goal is to
promote
health, prevent illness, and optimize the client's well-being
through
evidence-based nursing interventions and patient
education.

NURSING ASSESSMENT VS OTHER HEALTH CARE PROFESSIONALS'
ASSESSMENT
What
makes nursing assessment unique is its holistic approach,
which
considers not only the client's physiological status but also
their

psychological, sociocultural, developmental, and spiritual
dimensions.
Unlike other healthcare professionals who may focus
primarily
on specific aspects of health, such as physicians
concentrating
on physiological status or physical therapists focusing
on
musculoskeletal systems, nursing assessment integrates all these
dimensions
to provide comprehensive care.
Nurses
gather both subjective and objective data through
comprehensive
health histories, physical examinations, and
observations.

They
focus on understanding the client's responses to illness, coping
mechanisms,
health beliefs, values, and social support systems.
Nursing
assessments inform nursing diagnoses, care planning,
interventions,
and evaluation, aiming to address the client's holistic
needs
and promote well-being.
TYPES
OF NURSING ASSESSMENT
1.Initial Comprehensive Assessment-Collects
subjective and
objective
data about the client's overall health status, including
past
health history, family history, lifestyle, and physical
examination.
Establishes baseline data for future comparisons
and
interventions.
Example:
A nurse conducts an initial comprehensive assessment
on
a newly admitted patient to a hospital. The nurse gathers
subjective
data regarding the patient's medical history, current
symptoms,
past surgeries, family history of illnesses, and
lifestyle
habits.
Objective
data are collected through a thorough physical
examination,
including vital signs, neurological assessment,
cardiovascular
assessment, respiratory assessment, abdominal
assessment,
and musculoskeletal assessment.

7. 2.Ongoing Or Partial Assessment-Conducted
after the
comprehensive
database is established. Monitors changes in the
client's
health status, focusing on previously identified problems
and
detecting any new issues. Frequency determined by the
client's
acuity and the setting.
Example:
A nurse performs an ongoing or partial assessment on
a
patient admitted with congestive heart failure. The nurse
monitors
the patient's vital signs, heart rate, respiratory rate,
and
oxygen saturation at regular intervals to assess for any
changes
indicating worsening heart failure or complications.
The
nurse also reassesses lung sounds, peripheral edema, and
fluid
intake/output to monitor the patient's fluid status and
response
to treatment.
3.Focused or Problem-Oriented Assessment-Conducted
when a
client
presents with a specific health concern and a
comprehensive
database already exists. Thoroughly assesses the
problem
area without addressing unrelated aspects of health.
Example:
A patient presents to the emergency department with
complaints
of abdominal pain. The nurse conducts a focused or
problem-oriented
assessment specifically targeting the
abdomen.

The
nurse assesses the location, intensity. and characteristics of
the
pain, inquires about associated symptoms such as nausea or
vomiting,
and performs a focused abdominal examination to
identify
any potential causes of the pain, such as appendicitis or
gastrointestinal
issues.
4.Emergency Assessment-Rapid
assessment performed in life-
threatening
situations. Focuses on evaluating the
client's
Airway, Breathing, and Circulation (ABCs)
to provide immediate
treatment.
Example: A patient is brought to the emergency
room
after a motor vehicle accident with suspected head
trauma.
The nurse performs an emergency assessment focusing
on
the client's
AIRWAY, BREATHING, and CIRCULATION (ABCs).
The
nurse quickly assesses the patient's airway patency, breathing
rate
and effort, and circulation status, including pulse rate, blood
pressure,
and skin color, to identify any life-threatening injuries or
conditions
requiring immediate intervention.
NURSE’S ROLE IN HEALTH ASSESSMENT
A
nurse's role in health assessment is crucial as it forms the
foundation
for individualized care and the identification of health
problems.
Health assessment is a systematic approach used to
gather
data about a patient's physical, mental, and emotional health
status.
Here's a detailed breakdown of the nurse’s role in health
assessment:
1. Data Collection:
Objective Data (Physical Assessment):
The nurse conducts a
thorough
physical examination by inspecting, palpating, percussing,
and
auscultating various body systems (e.g., cardiovascular,
respiratory,
gastrointestinal, neurological).
Subjective Data (Patient History):
The nurse gathers the patient's
personal
and family medical history, lifestyle factors (e.g., diet,
exercise),
symptoms, and any concerns the patient has about their
health.
This is typically done through an interview process.
Use of Tools:
Nurses may use screening tools, questionnaires, or
assessment
scales to assess various aspects of health, including
mental
status, pain, and developmental milestones.
2. Holistic Assessment:
Physical Health:
Nurses assess vital signs, body systems, and overall
physical
condition to detect any deviations from normal health.
Psychosocial Health:
Nurses evaluate mental health, stress levels,
emotional
well-being, and the patient's coping mechanisms.

8. Cultural and Social Considerations:
Nurses consider cultural,
spiritual,
and social factors that might influence the patient’s health,
attitudes,
and behaviors.
Functional Assessment:
Nurses assess the patient’s ability to
perform
activities of daily living (ADLs) and other functional abilities,
which
can help determine the level of independence or need for
support.
3. Clinical Judgment:
Nurses
use critical thinking to interpret the data collected,
identifying
potential health problems or changes in the patient's
condition.
They
prioritize health issues based on the patient's needs and safety
concerns,
considering both immediate and long-term health goals.
Nurses
differentiate between normal and abnormal findings,
recognizing
subtle signs and symptoms that might indicate
underlying
health problems.
4. Patient Education:
Nurses
play an essential role in educating patients about their health
status,
risk factors, preventive measures, and self-care techniques.
During
the assessment, nurses provide explanations to help patients
understand
procedures and encourage open communication for
more
accurate information.
5. Collaboration:
Nurses
collaborate with the healthcare team to gather additional
insights
from physicians, specialists, and other professionals to
provide
comprehensive care.
They
also involve the patient and their family in the assessment
process
to ensure that the patient’s goals and preferences are
considered
in the care plan.
6. Documentation:
Accurate
and comprehensive documentation of health assessment
findings
is critical for continuity of care, communication among
healthcare
providers, and legal purposes.
Nurses
must ensure that all relevant information, including
observations
and patient responses, is documented clearly and
correctly.
7. Ongoing Assessment:
Health
assessments are not one-time events. Nurses must
continually
reassess the patient’s condition, especially if there are
changes
in symptoms, response to treatment, or new health
concerns.
This
ongoing process ensures that care remains patient-centered
and
adjusts to any evolving health needs.
8. Evaluation:
After
gathering assessment data, nurses evaluate the effectiveness
of
existing interventions and make necessary adjustments based on
their
findings.
Nurses
ensure that the patient’s health status and progress are
regularly
monitored, and new goals or strategies are developed
when
needed.
nurses
play an integral role in health assessment by collecting
comprehensive
data, utilizing critical thinking and clinical judgment,
collaborating
with the healthcare team, and advocating for patient-
centered
care. The assessment process is continuous and helps
guide
decision-making for effective, personalized patient care.