Health Assessment | Lecture To accomplish this, the registered nurse:

● Derives the dx or issues based on

Definition of Nursing assessment data
- Emphasis is placed on “ diagnosis ● Validates the dx or issues with the
and treatment of human responses” client, family, and other health care
based on “accurate client providers where possible and
assessment” appropriate
___________________________________
Nursing Scope and Standards of Practice
states that: Phases of Nursing Process
“The registered nurse collects ● Assessment - collecting subjective
comprehensive data pertinent to the patient’s and objective data (gather
health or situation” information about the patient’s
condition)
To accomplish this pertinent and ● Diagnosis - analyzing data to make a
comprehensive data collection, the nurse: professional nursing judgment
● Collects data in a systematic and (identify the patient’s problems)
ongoing process ● Planning - determine outcome
● Involves the patient, family, and criteria and develop a plan (set goals
other health care providers and of care and desired outcomes and
environment, as appropriate in identify appropriate nursing actions)
holistic data collection ● Implementation - carrying out the
● Uses appropriate evidenced-based plan (perform the nursing actions
assessment techniques and identified in planning)
instruments in collecting pertinent ● Evaluation - Assessing whether
data outcome criteria has been met and
● Uses analytical models and revising the plan as necessary (
problem-solving tools determine goals and expected
● Synthesizes available data, outcomes are achieved
information and knowledge related
to the situation to identify patterns Assessment
and variances - First and the most critical phase of
● Documents relevant data in a the nursing process – if the data
retrievable format collection is inadequate and
inaccurate then the nursing judgment
Standard 2 is incorrect.
“The registered nurse analyzes the - Is ongoing and continuous
assessment data to determine the diagnosis throughout all the phases of the
or issue.” nursing process
 - Purposes: to collect subjective and - thorough assessment of a particular
objective data, determine a client’s client problems and does not cover
overall level of fxng, in order to areas not related to the problem
make a professional clinical
judgment ● Emergency Assessment
- very rapid assessment performed in
Types of Assessment life threatening situations
● Initial comprehensive Assessment - major and only concern: to
- involves collection of subjective determine the status of the client’s
data about the client’s perception of life sustaining physical functions
her health of all body parts or
systems, past health history, family 4 Phases of the Assessment Phase of the
history and lifestyle and health Nursing Process:
practices ● Collection of the subjective and
- objective data gathered during a objective data
step by step PE ● Organizing the data
● Validation of data
● Ongoing or Partial Assessment ● Documentation of data
- consists of data collection that
occurs after the comprehensive Preparation
database is established 1. Review the patient’s record if
- consist of: available
mini-overview of client’s 2. Take a minute or two to reflect on
body systems and holistic your own feelings regarding on your
health patterns as a follow-up initial encounter with the client
on his health status. 3. Obtain and organize materials that
Initially collected - you will need for the assessment
reassessed to determine any
major changes (deterioration Collecting Subjective Data
or improvement) Subjective data - elicited and verified only
To detect any new problem by the pt sensation or symptoms, feelings,
Performed whenever the perceptions, desires, preferences, beliefs,
nurse or another health care ideas, and personal information.
professional has an encounter
with the client Areas of Subjective Data:
Biographical information
● Focused or Problem-Oriented Physical symptoms related to each
Assessment body part or system
Past health history
Family history
 Health and lifestyle practices conclusions are made when data are
- data elicited and verifies by client analyzed
- sources: client, family, client record, other
health care professional
- methods: client interview
- skills: interview and therapeutic
communication skills, caring ability and
empathy, listening skills

Objective Data:
Physical characteristics
Body functions
Appearance
Behavior
Measurements
Results of lab testing
- data directly or indirectly observed through
measurement
- sources: observations and PA findings of
the nurse or other healthcare professionals,
documentation of assessment made in client
record or observations made by family
- methods: observation and PE
- skills: IPPA (Inspection, Palpation,
Percussion, Auscultation)

Validating
1. Serves to ensure that the assessment
process is not ended before all
relevant data have been collected
2. Helps to prevent documentation of
inaccurate data

Documenting
1. Forms the database
2. Provides data for all other members
of the healthcare team
3. Thorough and accurate
documentation – ensure valid
Health Assessment - nurse listens, observes cues, and uses
critical thinking skills to interpret
___________________________ and validate info
4. Summary and Closing Phase
Collecting Subjective Data - nurse summarizes info obtained
Subjective data: during the working phase and
- elicited and verified only by the validates problems and goals with
client the client
- provide clues to possible - identifies and discusses possible
physiological, psychological and plans to resolve the problem
sociological problems - Ask if anything else concerns the
- obtained through interviewing client and if there are any further
questions
Interviewing
2 focuses: Communication During The Interview
Establishing rapport and a trusting 1. Verbal Communication
relationship with the client to elicit 2. Non-verbal Communication
accurate and meaningful information
Gather information Non-verbal Communication
Appearance
Phases of Interview Demeanor
1. Pre-introductory Phase Facial Expression
- review the medical record before Attitude
meeting with the client Silence
- past health history Listening
- reasons for seeking healthcare
2. Introductory Phase Verbal Communication
- introduces Open-ended questions:
- explains the purpose of the interview - Used to elicit feelings and
- discusses the questions perceptions
- explains the reasons for taking notes - Require more than one word
- assures the client confidentiality response from the client
- comfortable and privacy - Reveal significant information
- develop trust and privacy Closed-ended questions:
- begin by conveying a sense of - To obtain facts and to focus on
priority and interest in the client specific info
3. Working Phase - Useful in keeping the interview on
- nurse elicits information course
- To clarify or obtain more accurate
data
Non-verbal communication to avoid: - Speak slowly
- Excessive or insufficient eye contact - Face client
- Distraction and distance - Do not yell
- Standing - Position – on the side with better
hearing
Verbal communication to avoid: - Speak clearly
- Biased or Leading Questions - Simple terms
- Rushing through the Interview - No slang
- Reading the Questions
Complete Health History
Laundry List - Excellent way to begin the
- A choice of words to choose from in assessment
describing symptoms, conditions, - Lay the groundwork for identifying
and feelings any problems and provides focus for
- Help to obtain specific answers the PE
- Repeat the choices as necessary - Provide information that will assist
the examiner in identifying areas of
Rephrasing strength and limitation
- Clarify info - Provide specific cues to health
- Enables you and the client to reflect problems that are most apparent to
on what was said client

Well-Placed Phrases 8 Sections:

- “Um-hum” Biographical data
- “Yes” - information about a patient’s
- “I agree” history and behavioral patterns,
gathered by a therapist or medical
Inferring professional primarily from the
- What the client tells you and what patient but sometimes from others
you observe who know or are related to him or
- Ex. abdominal pain – note where the her.
client places her hands Reasons for seeking health care
- It recognizes that clients are
Providing Information complex beings, with potentially
- Provide the client with info as multiple co-existing health needs,
questions and concerns arise and often there is a pressing issue
- Answer questions that requires most immediate care.
- Knowledgeable–participative This is not to suggest that other
issues be ignored, but rather it allows
Elderly
providers, clients, and care partners and developmentally appropriate and
to stay focused. to modify care as based on the age
History of present health concern related characteristics and needs of
- is usually a chronological our clients.
description of the progression of the
patient’s present illness from the first
sign and symptom to the present.
Past health history
- details about any health problems
you’ve ever had – This information
gives your doctor all kinds of
important clues about what’s going
on with your health.
Family health history
- is a record of health information
about a person and his or her close
relatives. A complete record includes
information from three generations
of relatives, including children,
brothers and sisters, parents, aunts
and uncles, nieces and nephews,
grandparents, and cousins.
Review of body system
- is a list of closed ended questions
intended to uncover any recent
symptoms that haven’t already come
up.

Lifestyle and health practices profile

- focus more on preventative
measures rather than physical health
examinations, which may evaluate
current health status. Lifestyle
assessments focus on long-term
health and making positive changes
to health to improve longevity.
Developmental level
- assessed to determine if the client is
at the expected level of growth and
development, to plan care that is age