Chapter 1-HA

Download as ppt, pdf, or txt
Download as ppt, pdf, or txt
You are on page 1of 21

HEALTH ASSESSMENT

• A health assessment is a plan of care that identifies the


specific needs of a person and how those needs will be
addressed by the healthcare system or skilled nursing
facility. Health assessment is the evaluation of the health
status by performing a physical exam after taking a
health history.
• A health assessment is a set of questions, answered by
patients, that asks about personal behaviors, risks, life-
changing events, health goals and priorities, and overall
health.
• Gordon’s Functional Health Pattern

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Weber
Health Assessment in Nursing

Chapter 01: Nurse’s Role in


Health Assessment: Collecting
and Analyzing Data

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


• Nursing ( American Nurses Association- 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, community and populations.
• That the registered nurse collects comprehensive data
pertinent to the patient's health or situation.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


• To accomplish this pertinent and comprehensive data collection, the
nurse:
• 1. collects data in a systematic and ongoing process
• 2. involves the patient, family, other health care providers and
environment, as appropriate, in holistic data collection.
• 3. Prioritizes data collection activities based on the patient’s
immediate condition, or anticipated needs of the patient or situation.
• 4. uses appropriate evidence-based assessment techniques and
instruments in collecting pertinent data
• 5. uses analytical models and problem-solving tools
• 6. synthesizes available data, information, and knowledge relevant to
the situation to identify patterns and variances.
• 7. documents relevant data in a retrievable format.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


• “The registered nurse analyzes the assessment data to determine the
diagnoses or issues.
• To accomplish this, the registered nurse:
• 1. Derives the diagnosis or issues based on assessment data (Nursing
Assessment Form)
• 2. Validates the diagnoses or issues with the client, family, and other
healthcare providers when possible and appropriate
• 3. Documents diagnoses or issues in a manner that facilitates the
determination of the expected outcomes and plan

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Assessment- step 1 of the nursing process

• Nursing assessment
• Collecting subjective and objective data to
determine a client’s overall level of functioning in
order to make a professional clinical judgment
• Medical assessment
• Focuses primarily on the client’s physiologic
development status
• Nursing Care Plan (NCP)

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Phases of the Nursing Process

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
TYPES OF HEALTH ASSESSMENT
• 1. Initial Comprehensive Assessment
• 4 sections asked in each physical system:
• Collection of subjective data about the client’s perception of health of all body
parts or systems
• History of present health concern
• Past medical history-  a narrative or record of past events and circumstances
that are or may be relevant to a patient's current state of health. Informally,
an account of past diseases, injuries, treatments, and other
strictly medical facts.
• Family 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.
• Lifestyle and health practices

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Types of Assessment
• 2.Ongoing or partial assessment: consists of data collection that
occurs after the comprehensive data base is established.
• - problems that were initially detected are reassessed to determine
any changes (deterioration or improvement)
• 3.Focused or problem-oriented assessment: consists of a thorough
assessment of a client problem and does not cover areas not related
to the problem
• 4. Emergency assessment: very rapid assessment performed in life-
threatening situations

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Steps of Health Assessment

• Preparing for the assessment


– Review client’s record
– Review client’s status with other
health care team members
– Educate about client’s diagnosis and
tests performed

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


1.Collection of Subjective Data

• Biographical information
• Physical symptoms related to each body part or
system
• Past health history
• Family history
• Health and lifestyle practices 

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Collection of Objective Data

• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Comparing Subjective and
Objective Data

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Steps of Health Assessment

• Validating assessment data


• Documenting data

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Analysis Phase of Nursing Process
• Identify abnormal data and strengths.
• Cluster the data.
• Draw inferences and identify problems.
• Propose possible nursing diagnoses.
• Check for defining characteristics of those diagnoses.
• Confirm or rule out nursing diagnoses.
• Document conclusions.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Evolution of the Nurse’s Role in
Health Assessment: Past
• Physical assessment integral part of nursing
• Nurses relied on natural senses
• Palpation
• Movement of health care from acute care
setting to community care and proliferation of
baccalaureate and education
• Advanced practice nurses

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Evolution of the Nurse’s Role in
Health Assessment: Present
• Managed care and internal case management has
impact on assessment role of the nurse
– Acute care nurses
– Critical care outreach nurses
– Ambulatory care nurses
– Home health nurses
– Public health nurses
– School and hospice nurses

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


Evolution of the Nurse’s Role in
Health Assessment: Future
• Rising educational cost
• Increasing complexity of acute care
• Growing aging population
• Expanding health care needs
• Increasing impact of children and homeless
• Intensifying mental health issues
• Expanding health services network
• Increasing reimbursement for health promotion and
preventive care services

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins


• END

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

You might also like