Health Assessment in Nursing

• Introduction to Health Assessment

Introduction to Health Assessment in Nursing

• Professional nurses constantly observe and gather data.
• Information is collected to make informed nursing judgments.
• This occurs across settings like hospitals, clinics, homes, and long-term care facilities.
• Frequent informal assessments are part of a nurse's routine.
• Professional nursing assessments on patients, families, or communities dictate nursing interventions affecting their health.
• Nursing includes the protection, promotion, and optimization of health and abilities as a priority.
• Nursing plays a role in preventing illness and injury.
• Nurses provide advocacy in the care of individuals, families, and communities.
• Additionally, nurses offer alleviation of patient suffering through diagnosis and treatment of human responses.
• Five core competencies involve patient-centered care, teamwork, use of evidence-based practice, quality improvement, and informatics.
• Health assessment is a systematic method of collecting and analyzing data for patient-centered care planning.
• Health data is collected and compared to an ideal state.
• Considerations such as the patient’s age, gender, culture, ethnicity, and socioeconomic status are taken into account.
• Data about patient's strengths, weaknesses, health problems, alongside deficits is identified.
• Nurses use patient information like knowledge, motivation, and coping ability to develop a plan of care.

What is Health Assessment?

• Health assessment involves gathering data, analysis, making judgments, plus evaluating patient outcomes.
• Systematic data gathering and analysis are the initial steps in nursing care.
• Assessments include physiological, psychological, sociocultural, spiritual, economic, and life-style factors to get a complete view of the situation.
• The data collected can vary depending on the patient's condition, health history, and immediate symptoms.
• Immediate information is gathered in an emergency to pinpoint the issue and begin treatment.
• Assessments help establish databases, measure progress, identify trends, decide on logical data interventions, and evaluate the outcomes.
• The nursing process has eight steps; assess patient, analyze patient data, diagnose, determine outcomes, care plan, adjust plan, implement, and evaluate
• The nursing process is applicable in all stages of life and in all settings.
• It involves assessment, diagnosis, planning, implementation, and evaluation
• Health assessments go beyond simple data collection.
• Analysis of data facilitates effective judgments with nursing interventions.
• Consider the nursing process as circular, so its continuous.

Components of Health Assessment

• Health assessments involves a health history and a physical exam.
• Data findings should be documented.
• Data analysis and interpretation lead to patient-centered care.
• Gathering data depends on the situation, and the need of the patient.
• Health assessment is holistic and dynamic with continuous data collection, analysis and interpretation.
• Reviewing other data should be reviewed such as lab results.

Health History

• It consists of the subjective data collected during patient interviews.
• Health assessment is an important part of the nursing process.
• It entails a patient’s current health, current medications, or family history,
• Subjective data acquired directly from a patient is considered primary source data.
• Information from another person is secondary source data.
• Signs are objective data signs are what can see signs like swelling, and are measureable.
• Symptoms are subjective data, what patients can tell you, sensations such as feeling pain, and itching
• All of this should be documented correctly, concisely and the point of care

Physical Examination

• Objective data is collected, it is referred to as signs.
• Can be gathered via, inspection, palpation, percussion, and auscultation..
• Weight, height, blood pressure, temperature, pulse rate, are all taken.

Types of Nursing Assessments

• Three common types are Emergency, Comprehensive, and Focused.
• Emergency and focused center on the immediate problem.
• Comprehensive assessments are broad and thorough.
• Types of info gathering depends on patient condition and purpose.
• The emergency assessment is triggered by life-threatening situations.
• Mnemonic ABCDE is useful when triaging a patient
• ABCDE: assess airway, breathing, circulation, disability, and exposure
• Assess A, B, and C first with breathing at a rate a depth, and finally check the pulse
• Comprehensive assessments include complete health history and physical exam.

Clinical Judgement

• Its a portrait of a patient’s physical status.
• Includes, strengths and weaknesses, and abilities.
• Encompasses support systems, health beliefs, and activities.
• Nurses need to analyze and interpret data.
• Consider the best course of plans.
• Physical assessment is not just a task.
• Collecting data alone is useless unless used to benefit the patient.
• Its important to be monitoring the patient to see subtle changes.
• A key is early recognition of data through assessment.
• Nurses need to recognize any change in a patient by detecting a deteriorating status to avoid further complications.

Data Organization

• Nurses organize data after it is recorded.
• Data may group by body system or cardiovascular.

Data Analysis & Interpretation

• It refers to the formulation of problem list that summarizes health problems.
• Findings should be normal, but any abnormal can be used to properly treat.
• Key is to identify to help patients and create a plan of care.
• The most and active will be put at the top to handle first.
• Its updated as condition changes, or problems resolve to show any and further issues.

Clinical Judgement

• Is an interpretation/conclusion about health problems.
• Clinical judgement needs an collection of assessment data, the data will guide nursing actions.
• Clinical judgment needs experience, knowledge, and attitudes.

Priority Setting

• Is an important professional skill.
• Important to use clinical experience.
• Some expert nurses prioritize differently.
• Always consider life-threatening problems that always take priority.
• You are spending a lot of time it is most important to take care of.

Frequency of Assessment

• Can vary with the patient’s needs, purpose of data collection, and health care setting.
• Long term patients only need comprehensive assessment once a month.
• Acute patients are assessed once per day.
• The facility standard of care is minimum.