Health Assessment NCM 101 d.

Reviewing the client’s chart & the

literature
The Contents REVIEW OF THE NURSING
PROCESS 01 e. Consult with the client, his significant
others
A – Assessment
2. Constantly update the data base to
D – Diagnosis
reflect client changes
O – Outcome Identification
3. Validate all data
P – Planning
4. Communicate the data
I – Intervention
ASSESSMENT TAKES PLACE IN ALL
E - Evaluation REALMS: PHYSICAL, MENTAL,
EMOTIONAL, CULTURAL, SPIRITUAL
What is Nursing Process? AND SOCIO-ENVIRONMENTAL!!!
- is a critical thinking process that ASSESSMENT TYPES OF NSG.
professional nurses use to apply the best
available evidence to caregiving and 1. Initial Comprehensive Assessment
promoting human functions and responses
2. Ongoing or Partial Assessment
to health and illness (American Nurses
Association, 2010). 3. Focused or Problem Oriented Assessment

What is Nursing Process? 4. Emergency Assessment

- Nursing process is a systematic method of Types of Data Two types:

providing care to clients.
1. Subjective data: also referred to as
- The nursing process is a systematic symptoms or covert data, are clear only to
method of planning and providing the person affected and can be described
individualized nursing care. only by that person. Itching, pain, and
feelings of worry are examples of subjective
Purposes of Nursing Process
data.
- To identify a client’s health status and
2. Objective data: also referred to as signs
actual or potential health care problems or
or overt data, are detectable by an observer
needs. - To establish plans to meet the
or can be measured or tested against an
identified needs.
accepted standard. They can be seen, heard,
• To deliver specific nursing interventions felt, or smelled, and they are obtained by
to meet those needs. observation or physical examination. For
example, a discoloration of the skin or a
Components of Nursing Process blood pressure reading is objective data.
A D O P I E ASSESSMENT DIAGNOSIS
is a continuous, systematic collection, - Diagnosis is the second phase of the
validation and communication of client nursing process. In this phase, nurses use
data. critical thinking skills to interpret
ASSESSMENT IS CONTINUOUSLY assessment data to identify client problems.
UPDATED!!! - North American Nursing Diagnosis
Association (NANDA) define or refine
Steps in the assessment phase of the nursing diagnosis.
nursing process:
DIAGNOSIS - The Nursing Diagnosis
1. Establish a data base by Describes Only Problems That Can Be
a. Taking the client’s vital signs Handled By Nurses!!!!!

b. Performing a head to toe examination - The nursing diagnosis describes a human

response
c. Taking a complete nursing history
- The nursing diagnosis differs from the 2. THE ETIOLOGY (CAUSE OF THE
medical diagnosis, but should complement PROBLEM)ie: Related to (R/T) low residue
it DIAGNOSIS The official NANDA diet and lack of exercise
definition of a nursing diagnosis is: “a
3. THE EVIDENCE FOR THE PROBLEM:
clinical judgment concerning a human
As evidenced by(AEB) no stool for five days
response to health conditions/life
Putting it all together: Constipation, R/T
processes, or a vulnerability for that
low residue diet & lack of exercise As
response, by an individual, family, group,
Evidenced By no stool for five days
or community.”
WRITING THE NURSING DIAGNOSIS: IN
The status of nursing diagnosis are actual,
3 STEPS
health promotion and risk:
Acute pain related to abdominal surgery as
1. An actual diagnosis is a client problem
evidenced by patient discomfort and pain
that is present at the time of the nursing
scale
assessment.
Differentiating Nursing Diagnosis from
2. A health promotion diagnosis relates to
Medical Diagnosis:
clients’ preparedness to improve their
health condition. - A nursing diagnosis is a statement of
nursing judgment that made by nurse, by
3. A risk nursing diagnosis is a clinical
their education, experience, and expertise,
judgement that a problem does not exist,
are licensed to treat.
but the presence of risk factors indicates
that a problem may develop if adequate - Nursing diagnoses describe the human
care is not given. response to an illness or a health problem. -
Nursing diagnoses may change as the
DIAGNOSIS Components of a NANDA
client’s responses change.
Nursing Diagnosis:
- A medical diagnosis is made by a
(1) The problem and its definition -
physician.
describes the client’s health problem
- Medical diagnoses refer to disease
(2) The etiology - identifies causes of the
processes.
health problem
- A client’s medical diagnosis remains the
(3) The defining characteristics - are the
same for as long as the disease is present.
cluster of signs and symptoms that indicate
Ineffective breathing pattern Activity
the presence of health problem.
intolerance Acute pain Disturbed body
DIAGNOSIS STEPS IN MAKING THE image Asthma Cerebrovascular accident
NURSING DIAGNOSIS: Appendicitis Amputation Nursing VS
Medical
1. Interpret and validate client data; analyze
all data • Planning involves decision making and
problem solving.
2. Identify the client’s problems (and
strengths) • It is the process of formulating client goals
and designing the nursing interventions
3. Formulate and validate the nursing
required to prevent, reduce, or eliminate the
diagnoses, both actual & potential
client’s health problems.
4. Prioritize a list of appropriate nursing
diagnoses (No client has only one problem
in only one realm.) PLANNING

WRITING THE NURSING DIAGNOSIS: PLANNING (TO END, HEAL OR OVER-

IN 3 STEPS COME THE PROBLEMS IN THE

1. THE PROBLEM STATEMENT(NANDA)

ie: Constipation
PROBLEM STATEMENTS OF THE INTERVENTIONS ALWAYS ARE STATED
NURSING DIAGNOSES) “NURSE WILL”!! ie: Nurse will consult
with the client, dietician, and physician
1. Establish priorities (most life threatening
regarding upgrading client’s diet to a high
or disturbing first)
fiber diet. Nurse will walk with client,
2. Select and write down (in cooperation assisting and supporting him, the length of
with the client) the goals which are also the hall tid.
known as expected outcomes = goals.
IMPLEMENTATION IS THE ACTION
EXPECTED OUTCOMES (GOALS) MUST PHASE OF THE NURSING PROCESS
ALWAYS BE DATED OR TIMED!!! (when the nurse does something with, to, or
PLANNING GOALS MUST BE REALISTIC for the client) INTERVENTION
(in terms of the client’s potential for
- All actions (interventions) planned for the
achieving them & the nurse’s ability to help
client must be based on scientific principles
the client achieve them.)
and rationale.
GOALS SERVE AS GUIDES IN
- Interventions are based on the least
SELECTING NURSING INTERVENTIONS.
amount of discomfort, invasion and risk for
GOALS ARE ALWAYS STATED
the client.
BEGINNING WITH “CLIENT WILL” ie:
- The nurse never does for the client what
By Sept. 17, client will state what high fiber
he can safely and capably do for himself.
foods he prefers
(We’re not taking them to raise; we’re
By Sept. 18, client will eat one high fiber usually trying to return them to their life.)
food with each meal THE LAST STEP IN INTERVENTION IS
TO ACCURATELY DOCUMENT IT!!!
By Sept. 17, client will walk length of hall INTERVENTION
tid with assistance
- Nursing interventions require intellectual,
TYPES OF PLANNING interpersonal and technical skills.
1. Initial Planning : Planning which is done - Intellectual skills required of the nurse
after the initial assessment. include: problem identification, and
2. Ongoing Planning : It is a continuous problem solving, critical thinking, and the
planning. ability to make sound judgments.

3. Discharge Planning : Planning for needs - A strong theoretical background is

after discharge necessary for these intellectual skills!
INTERVENTION
Planning process Planning includes:
- Interpersonal skills used during nursing
• Setting priorities intervention include: communicating,
• Establishing client goals/desired listening, conveying interest, compassion,
outcomes empathy, and TLC. These skills are
invaluable in establishing rapport and
• Selecting nursing interventions and building a therapeutic relationship.
activities
- Technical skills refer to the performance of
• Writing individualized nursing procedures and the use of equipment and
interventions on care plans. materials competently and proficiently.
(Practice makes perfect!)

INTERVENTION
Nursing interventions can be:
NURSING INTERVENTIONS (ALSO
CALLED IMPLEMENTATIONS) 1. DEPENDENT
NURSING INTERVENTIONS MAKE THE
CLIENT GOALS COME TRUE!! NURSING
 ie: giving the patient a medication (the scientific manner. The Assessment first and
nurse is dependent on the physician to most critical phase of the nursing process.
write the medication order.)
Assessment Is the systematic and
2. COLLABORATIVE continuous:

ie: consulting with a colleague such as a • collection

dietician, physical therapist or another • organization
nurse before taking action.
• validation
3. INDEPENDENT
• documentation of data.
ie: when the nurse takes action alone, such
The Process Assessment
as starting oxygen on a client who has
become cyanotic or beginning one man Collect data
rescue CPR.
Organize data
EVALUATION
Validate data
The last phase of the nursing process is Documenting data
EVALUATION. Our patient goals and
nursing actions are useless if we are not • The nurse gathers information to identify
constantly evaluating whether or not they the health status of the patient.
are making any headway in returning the • Assessments are made initially and
client to health and functioning. continuously throughout patient care.
EVALUATION MEASURES THE DEGREE • The remaining phases of the nursing
TO WHICH THE NURSING PROCESS process depend on the validity and
HAS BEEN SUCCESSFUL. EVALUATION completeness of the initial data collection.
MEANS WE REASSESS AT EACH STEP
Purposes of assessment
TO ASSURE EFFECTIVENESS AND
ACCURACY. To establish Database: all the information
about a client it includes:
Common evaluation outcomes:
• The nursing health history
1. Client responded as expected, problem is
solved, goals effective • Physical examination

2. Client’s problem has not been resolved, • The physician's history

even though expected outcomes were • Results of laboratory and diagnostic tests
accomplished. Re-evaluate, make new Assessment is part of each activity the nurse
problem solving goals. does for and with the patient.

3. Client’s problem has not been resolved The purposes is

and has,in fact, worsened. Replanning is
1.To validate a diagnosis
urgently needed.
2.To provide basis for effective nursing care.
4. Client has manifested a new problem;
nursing process begins all over again. 3.It helps in effective decision making
4.Basis for accurate diagnosis

Nursing Assessment process: 5.It promote holistic nursing care

Is a systematic method by which nursing: 6.To provide effective and innovative

plans and provides care for patients. This nursing care
involves a problem-solving approach that 7.To collecting data for nursing research
enables the nurse to identify patient
problems and potential at-risk needs 8.To evaluation of nursing care PURPOSE
(problems) and to plan, deliver, and
Types of Assessment
evaluate nursing care in an orderly,
Focus Assessment
Initial Assessment clinic visits, home health visits, health and
development screenings)
Time-lapsed Assessment
STEPS OF ASSESSMENT
Emergency Assessment
A. Collection of data
a) Subjective data collection
Initial comprehensive assessment
b) Objective data collection
An initial assessment, also called an
admission assessment, is performed when B. Validation of data
the client enters a health care from a health
care agency. The purposes are to evaluate C. Organization of data
the client’s health status, to identify D. Recording/documentation of data
functional health patterns that are Collection of Data
problematic, and to provide an in-depth,
comprehensive database, which is critical • gathering of information about the client
for evaluating changes in the client’s health • includes physical, psychological, emotion,
status in subsequent assessments. socio-cultural, spiritual factors that may
Problem-focused assessment affect client’s health status

A problem focus assessment collects data § includes past health history of client
about a problem that has already been (allergies, past surgeries, chronic diseases,
identified. This type of assessment has a use of folk healing methods)
narrower scope and a shorter time frame § includes current/present problems of
than the initial assessment. In focus client (pain, nausea, sleep pattern, religious
assessments, nurse determine whether the practices, medication or treatment the client
problems still exists and whether the status is taking now)
of the problem has changed (i.e. improved,
worsened, or resolved). This assessment Types of Data
also includes the appraisal of any new,
overlooked, or misdiagnosed problems. In When performing an assessment the nurse
intensive care units, may perform focus gathers subjective and objective data.
assessment every few minute. Subjective data (symptoms or covert data):
Emergency assessment are the verbal statements provided by the
Patient. Statements about nausea and
Emergency assessment takes place in life- descriptions of pain and fatigue are
threatening situations in which the examples of subjective data. Objective data
preservation of life is the top priority. Time (signs or overt data), are detectable by an
is of the essence rapid identification of and observer or can be measured or tested
intervention for the client’s health against an accepted standard. They can be
problems. Often the client’s difficulties seen, heard, felt, or smelt, and they are
involve airway, breathing and circulatory obtained by observation or physical
problems (the ABCs). Abrupt changes in examination. For example: discoloration of
self-concept (suicidal thoughts) or roles or the skin
relationships (social conflict leading to
violent acts) can also initiate an emergency. Objective Data
Emergency assessment focuses on few Data Collection Methods
essential health patterns and is not
comprehensive. 1. Observing: to observe is to gather data by
using the senses.
Time-lapsed assessment or Ongoing
assessment 2. Interviewing: an interview is a planned
communication or conversation with a
Time lapsed reassessment, another type of purpose.
assessment, takes place after the initial
assessment to evaluate any changes in the 3. Examining: Performance of a physical
clients functional health. Nurses perform examination. The physical examination is
time-lapsed reassessment when substantial often guided by data provided by the
periods of time have elapsed between patient. A head-to-toe approach is
assessments (e.g., periodic output patient frequently used to provide systematic
approach that helps to avoid omitting E.g.: the nurse record the client's breakfast
important data intake as" coffee 240 mL. Juice 120 mL, 1
egg". Rather than as "appetite good".
Physical assessment
Purposes of documentation
• Head – to - Toe Assessment
• Provides a chronological source of client
• Body Systems Assessment assessment data and a progressive record of
4. Organizing data: The nurse uses a written assessment findings that outline the client’s
or computerized format that organizes the course of care.
assessment data systematically. The format • Ensures that information about the client
may be modified according to the client's and family is easily accessible to members
physical status. of the health care team; provides a vehicle
Body System Model for communication; and prevents
fragmentation, repetition, and delays in
The Body systems model (also called the carrying out the plan of care.
medical model or review of systems)
focuses on the client’s major anatomic • Establishes a basis for screening or
systems. validation proposed diagnoses.

The framework allows nurses to collect data • Acts as a source of information to help
about past and present condition of each diagnose new problems.
organ or body system and to examine • Offers a basis for determining the
thoroughly all body systems for actual and educational needs of the client, family, and
potential problems. significant others. • Provides a basis for
The client’s strengths, talents and functional determining eligibility for care and
health patterns are an integral part of the reimbursement. Careful recording of data
assessment data. can support financial reimbursement or
gain additional reimbursement for
An assessment of functional health focuses transitional or skilled care needed by the
on client’s normal function and his or her client.
altered function or risk for altered function.
• Constitutes a permanent legal record of
• Health perception-health management the care that was or was not given to the
pattern. client.
• Nutritional-metabolic pattern • Provides access to significant
epidemiologic data for future investigations
• Elimination pattern
and research and educational endeavors.
• Activity-exercise pattern Guidelines for documentation
• Sleep-rest pattern • Document legibly or print neatly in
unerasable ink
• Cognitive-perceptual pattern
• Use correct grammar and spelling
• Self-perception-concept pattern
• Avoid wordiness that creates redundancy
•Role-relationship pattern
• Use phrases instead of sentences to record
• Sexuality-reproductive pattern data
• Coping-stress tolerance pattern • Record data findings, not how they were
• Value-belief pattern Gordon’s Functional obtained
Health Patterns: • Write entries objectively without making
Documenting Data: premature judgments or diagnosis
Guidelines for documentation
To complete the assessment phase, the
nurse records client's data. Accurate • Record the client’s understanding and
documentation is essential and should perception of problems
include all data collected about the client's • Avoid recording the word “normal” for
health status. Data are recorded in a factual normal findings
manner and not interpreted by the nurse.
• Record complete information and details • Pattern of health care – includes all health
for all client symptoms or experiences care resources: hospitals, clinics, health
centers, family doctors.
• Include additional assessment content
when applicable Psychological And Social Examination
• Support objective data with specific • Client’s perception (why they think they
observations obtained during the physical have been referred/are being assessed;
examination what they hope to gain from the meeting)
Nursing Assessment • Emotional health (mental health state,
coping styles etc)
• Assessment is the first stage of the
nursing process in which the nurse should • Social health (accommodation, finances,
carry out a complete and holistic nursing relationships, genogram, employment
assessment of every patient's needs, status, ethnic back ground, support
regardless of the reason for the encounter. networks etc)
Usually, an assessment framework, based
on a nursing model is used. • Physical health (general health, illnesses,
previous history, appetite, weight, sleep
• The purpose of this stage is to identify the pattern, diurinal variations, alcohol,
patient's nursing problems. These problems tobacco, street drugs; list any prescribed
are expressed as either actual or potential. medication with comments on
For example, a patient who has been effectiveness) Psychological And Social
rendered immobile by a road traffic Examination
accident may be assessed as having the
"potential for impaired skin integrity related • Spiritual health (is religion important? If
to immobility". so, in what way? What/who provides a
sense of purpose?)
Components of a nursing assessment
• Intellectual health (cognitive functioning,
• Biographic data – name, address, age, sex, hallucinations, delusions, concentration,
martial status, occupation, religion. interests, hobbies etc
• Reason for visit/Chief complaint – primary Physical examination
reason why client seek consultation or
hospitalization. • A nursing assessment includes a physical
examination: the observation or
• History of present Illness – includes: usual measurement of signs, which can be
health status, chronological story, family observed or measured, or symptoms such
history, disability assessment. as nausea or vertigo, which can be felt by
the patient.
• Past Health History – includes all previous
immunizations, experiences with illness. • The techniques used may include
Inspection, Palpation, Auscultation and
• Family History – reveals risk factors for Percussion in addition to the "vital signs" of
certain disease diseases (Diabetes, temperature, blood pressure, pulse and
hypertension, cancer, mental illness). respiratory rate, and further examination of
• Review of systems – review of all health the body systems such as the cardiovascular
problems by body systems or musculoskeletal systems.

• Lifestyle – include personal habits, diets, Documentation of the assessment

sleep or rest patterns, activities of daily The assessment is documented in the
living, recreation or hobbies. patient's medical or nursing records, which
• Social data – include family relationships, may be on paper or as part of the electronic
ethnic and educational background, medical record which can be accessed by all
economic status, home and neighborhood members of the healthcare team.
conditions. Assessment Tools
• Psychological data – information about the The index of independence in activities of
client’s emotional state. daily living
• Activities of daily living (ADLs) are "the
things we normally do in daily living
including any daily activity we perform for
self-care (such as feeding ourselves,
bathing, dressing, grooming), work,
homemaking, and leisure."
The Barthel index
The Barthel Index consists of 10 items that
measure a person's daily functioning
specifically the activities of daily living and
mobility. The items include feeding, moving
from wheelchair to bed and return,
grooming, transferring to and from a toilet,
bathing, walking on level surface, going up
and down stairs, dressing, continence of
bowels and bladder.
• The general health questionnaire
• Mental health status examination
The Mental Status Exam (MSE) is a series of
questions and observations that provide a
snapshot of a client's current mental,
cognitive, and behavioural condition.
Conclusion Assessment is the first and most
critical step of nursing process. Accuracy of
assessment data affects all other phases of
the nursing process. A complete data base
of both subjective and objective data allows
the nurse to formulate nursing diagnosis,
develop client goals, and intervenes to
promote heath and prevent disease.