Untitled

Health Assessment: Introduction to the Nursing Process

• A plan of care identifies clients' specific needs and specifies how they will be addressed by healthcare organizations or skilled nursing facilities.
• Health assessment involves the evolution of the nurse’s role from the late 1800s to the present.

Expansion of the Nurse Role

• The nurse role is expanding rapidly, becoming more prevalent and encompassing new fields.

Fields with Median Salaries

• Home health nurses earn a median salary of $78,983, or $34-$41/hour, providing independent nursing diagnoses, referrals, and collaborative care.
• Public health nurses, focusing on community needs and children’s health, have a median salary of $56,111, or $24-$29/hour.
• School nurses also address community needs and children’s health, with a median salary of $49,168, or $21-$25/hour.
• Hospice nurses assess terminally ill clients and families, earning a median salary of $71,654, or $31-$37/hour.
• Acute care nurses conduct extensive focused assessments and earn a median salary of $73,500, or $31-$38/hour.
• Forensic nurses perform extensive focused assessments in a reversed process, with a median salary of $81,800, or $35-$42/hour.
• Critical care outreach nurses enhance skills to assess clients outside intensive care, earning a median salary of $62,822, or $27-$32/hour.
• Ambulatory care nurses assess clients for referral needs, with a median salary of $78,983, or $34-$41/hour, also performing forensic/legal nursing tests.
• Nurses document and retrieve assessment data increasingly through computerized systems.
• Informatics content is becoming standard in baccalaureate programs.
• Increased specialization and diversity of assessment skills are predicted to continue.
• Integrated clinical practice rises with surgical care, where nurses follow clients from preoperative care to multidisciplinary outpatient clinics and home via technology

Reasons for the Trend

• Rising educational costs, a focus shift to primary care, and the increasing complexity of acute care.
• Expanded healthcare needs for single parents, the impact of homeless and children, and intensifying mental health issues.
• Expanded health service networks with greater reimbursement for health promotion and preventative services.

Significance of Health Assessment

• It allows nurses to create nursing diagnoses, offer nursing care, and identify collaborative and referral requirements.
• Signifies analyzing data, judging nursing intervention effectiveness, and evaluating client care outcomes.

Overview of the Nursing Process

• A systemic and rational method that is cyclical, logical, and involves multiple components or phases to plan and deliver nursing care.

Nurse Responsibilities

• Conducting and documenting health status assessments, collecting data, adapting to status changes, and reporting to the health team.

Nurse Functions

• Independent functions include licensed actions based on knowledge and skills, such as physical care, ongoing assessment, emotional support, teaching, counseling, environmental management, and making referrals.
• Dependent functions are performed under supervision with authorized orders from providers, including medication, IV therapy, tests, treatments, diet, and activity administration.
• Interdependent/collaborative functions require collaboration with other professionals like physical therapists, social workers, dietitians, and primary care providers.

Criteria for Interventions

• Must be safe, appropriate, achievable, congruent with client values, and based on nursing knowledge within standards of care.

Beginning the Nursing Process

• The assessment is systematic, deliberate, and continuous across all phases to collect and analyze patient data; it is also the most critical phase.

Focus of Health Assessment

• Collecting holistic subjective and objective client data, including physiological, psychological, developmental, and spiritual information, to determine overall functioning; focuses on how health affects daily living and how clients interact within, and are affected by, community and family.

Nursing vs Other Professions in Assessment

• Nursing includes subjective, objective, physiological, sociocultural, psychological, and spiritual data, while others like Medical Doctors, Physical Therapists, and Respiratory Therapists focus on one aspect with different frameworks.

NHA vs MD Assessment

• Very similar but define the focus and scope of practice; questions may be similar, but underlying rationales differ, with physicians diagnosing/treating illnesses while nurses diagnose/treat responses to health problems, which is how collaboration looks like.
• Complete Blood Count / Chest Radiograph- diagnosis for doctors, comparison of diagnosis / medical or nursing management for nurses

Skills of Assessment

• Cognitive skills are needed for critical thinking and clinical decision-making, using theoretical knowledge to assess and identify problems, reflect, reason, inquire, interpret, analyze, and synthesize.

Types of Health Assessment

• Initial Comprehensive: Total assessment with participation of other specialists (e.g. physician, PT, dietitian).
• Ongoing or Partial: After comprehensive, with mini-overview of systems as follow-up for changes.
• Focused or Problem-Oriented: Assess a particular problem and doesn't replace a comprehensive.
• Emergency: Rapid assessment during life-threatening situations to determine life-sustaining functions status.

Steps of the Health Assessment

• Collect Subjective and Objective Data, validate it and document it; may require performing 2 or 3 steps concurrently.

Preparing for the Assessment

• Review records to familiarize with biographical data and awareness of past/current health status to guide interactions along with information from other health team members.
• Keep an open mind and avoid prejudice (decreases accuracy of data) as well as use time to educate self about relevant diagnosis and tests: Use available resources like laboratory or textbooks; be self-aware of own feelings regarding first encounter with cases like addiction, STDs, or cognitive limitations to remain open and objective; prepare all necessary equipments, interview questions/forms and tools..

Data Collection and Databases

• Data collection is gathering health status information. A database includes all information, like nursing history, examinations, tests, and other member contributions.

Collecting Subjective Data

• Subjective entails sensations, feelings, perceptions, desires, beliefs, ideas, and values elicited and verified only by the client Major areas include biographical info, health concern history, medical history, health and lifestyle practices..

Collecting Objective Data

• Objective data, directly observed by the examiner, includes characteristics, body functions/appearance, behaviours, measurements, testing results (i.e. inspect, auscultate, palpate, percuss)..
• Comes from EMHR (other healthcare source entries) or family; these validate subjective data to complete assessment phase.

Validation of Data

• A crucial part of the data-gathering process, which goes along collecting, ends when all is relevant and prevents premature conclusion and helps prevent inaccurate documenting to verify data reliability, with steps to: decide, determine validation ways, identify missing areas and: don't require All data Validation, validated discrepancies, subjective vs objective, time differences, abnormal findings.

Methods of Validation

• Recheck own data, ask questions to clarify, verify with another profession, and compare objective with subjective findings.

Identifying Missing Data

• Go through your database and consider overlooked areas like 98 lbs (lost weight over time) or lives alone (support, function and care level).

Sources of Data

• Primary: The source of data is the client and unless they are ill, young, and not clear so subjective Emphasis emphasis here
• Secondary: System Support All sources come other than from source Support system or family and care giver etc, medical record, other team members, or other journals/literature.

Data Collection Methods

• Interview- a planned/ purposeful conversation with Directive, highly structured to elicit, close ended data w/ control or Non-Directive letting client control subject, pace w/ open ended q's. The Interview Questions.
• Observation: Gathering data with the senses: vision (body size, lesions), smell (odors), hearing (lung, heart), touch (temperature and moisture).
• Physical Assessment: Careful Inspection, listening through stethoscope or Auscultation, palpation or touching, the obsolete percussion and stethoscope facts!.
• Medical Records Review: Add more to complete assessment.

Organizing the data

• Computerize format system, using, or written models based out what nursing/non nursing are what's Wellness to Maslow hierarchies/Body Development systems (Maslow / Gordon 11 Func Patterns).

Documenting the Data

• Consider Nurse's description of patient' Breakfast factual recording, or avoiding interoperation or saying the opposite to use client's words for accuracy.

Patient Positions: Supine

• If client has trouble breathing keep head elevated, promotes abd. muscles relaxation Head and Check assesed

Sitting

Anterior/Posterior chest are assed for Cardiac/Resp, good lungs/Resp expention, weakness and paralysis

Dorsal Recumbent

• Similar to Supine abdomen with flexing knees, comfy

Prone

• Prone can assess head and neck area

Sims

• may be best for a rectal exam

Lithotomy

Embarrassment, May require use to assist, and keep pt. well draped.

Patient Guidelines

• include, and use when assessment is followed systematic comprehensive collection/validation etc data

Consider Patients and age

• New born
• Infant
• Elder
• Pregnant

Physical Environment and Patient Rights

• Keep room in a Quite environment
• Let Pt get copy of their own record
• Pt Has Right on how and other shares their info
• Pts has right of confidentiality

Cultural, and spiritual, Family Consideration

• Systems are connected
• Have to change during internal interaction or change

What is culture

• latin Word "comptere" to survive all the behavioral pattern Values and thoughts process by population

Characteristics of culture

• is shared, is learned, adaptation in society Culture is learned - though experience via other cultural groups

Culture is Shared

• through behavior

Culture is Associated with Adaptation to Environment

• As it change people also change and develop due time

Culture is Universal

Cultures may vary between groups

Culture Compenetiece- and what happens throughout diff steps

Medical causes over other cultures

and other facts over culture from Native Americans, and other such cultures..

Phases of Diagnostic Testing

• involves pretest, intratest, and posttest phases including preparing the client, collecting gathering equipment, label testing then care throughout procedure.

Complete Blood Count (CBC)

• used to assess the patient for anemia, infection, information; evaluate if necessary

Chemistry

• Blood - including assessment of liver function, bilirubin, detect cardiac via finding creatine, lipase etc)
• Others - for serum and electrolyte tests. Blood tests can be used to look for abnormal results.

Hypothyroidism

• radioactive/ iodine to assess thyroid gland.

Stool Specimen

• is collected to test for the occult blood.

Specimen

• includes 1 to 2 tbsp sputum and lab transported for the doctor to review.

Visualizing Body for System function assessment - Gl.

Includes barium , x rays

Urinary Function Assessment and Visualization

• Done intravenously

Cytoscopy

(diagnoses structure and function of urinary bladder )

X ray

• direct for Kidney, ureter and Bladder

Electrodiagram

• Used to track heart

Stress Test

• is measured by external stress to measure for body reactions. Response is often given through drug or intravenous usage.)

Computerize

• Tomography (Distinguish differences and densities of tissue)

Magnetic

• Resonase imaging (Client should know that implanted metal can risk MRI use)

Nuclear

• imaging study that involves injecting/inhaled radioactive Isoplore

Aspiration

• Removal of fluid, collection assessment by biopsy/tissue analysis

• Spine - puncture -- Measure increases Pressure/ Detect blockages.

Assessment of the Neck

• Musculoskeletal System
• Includes all body structure, all systems.

Aspiration

• Withdrawal of fluid that has abnormally collected.