Health Assessment in Nursing

• Health assessment is a core skill for professional nurses, demanding constant observation and information gathering for informed nursing judgments across varied settings like hospitals, clinics, homes, and communities

Health Assessment in Nursing

• Involves the protection, promotion, and optimization of health and abilities
• Focuses on prevention of illness and promotion of comfort
• Includes advocacy in the care of individuals, families, and communities
• The Institute of demonstrate identifies 5 key competencies

Core competencies include

• Providing patient-centered care
• Working in interdisciplinary teams
• Using evidence-based practice
• Applying quality improvements
• Utilize informatics

Systematic Data Collection

• Health assessment is a systematic method of collecting and analyzing patient data
• All data should be used to plan patient-centered care
• Takes into account individual factors like age, gender, culture, ethnicity, and physical, psychological, and socioeconomic status

Patient-Centered Care

• The nurse identifies strengths, weaknesses, health problems, and deficits
• The nurse takes into account patient knowledge, motivation, support systems, coping ability, and preferences
• The nurse uses data to develop a plan of care that will help the patient to maximize his or her potential.

Defining Health Assessment

• Health assessment is the process of gathering information about a patient's health
• Analyzing and synthesizing data
• Making judgments about care
• Evaluating patient care outcomes

Assessment Characteristics

• Employs a systematic, dynamic approach to data collection and analysis.
• It serves as the initial step in delivering nursing care
• Encompasses not only physiological data but relevant factors like psychological, sociocultural, spiritual, economic, and lifestyle elements

Key Data Points

• Considers past medical and surgical histories, lifestyle, current symptoms
• Considers nutrition, development, mental health, culture, and safety issues

Data collection and analysis

• To establish a database for future comparisons, one should gain further insight into a patient's condition
• One must identify patterns and trends to determine whether a patient's condition is improving or worsening
• One must think logically to determine how pieces of data are related
• The nursing process includes implementation, and assessment becomes a continuous part of care

The Nursing Process

• Involves a deliberate, methodical problem-solving strategy to identify and manage both actual and potential health challenges.
• Functions as a framework for delivering individualized care to individuals, families, and communities
• Is focused and centers on solving problems and enhancing strengths, guided by ANA standards

Nursing Process Application

• Applicable to patients in all stages of life and in all settings
• Includes the following aspects:
• Assessment: gathering data
• Analysis
• Diagnosis
• Planning
• Implementation
• Evaluation

Assessment Phase

• The initial and most crucial phase of the nursing process
• Inadequate or inaccurate data collection leads to incorrect nursing judgments
• The process integrates information from different points to guide nursing actions
• Integrates data from patient history, physical examination, lab results, diagnostic/surgical procedures

Health history

• Consists of subjective data collected during an interview
• The nurse collects data regarding current health, medications, previous illnesses/surgeries, family history, and a review of systems

Data Sources

• Primary data comes directly from patients
• Considered subjective and are called symptoms
• Secondary data comes from others
• Objective data comes is collected during a physical examination and are considered signs

Examination techniques

• Techniques utilized are; inspection, palpation, percussion, and auscultation
• Measurements taken during physical assessment include height, weight, blood pressure, temperature, pulse, and oxygen saturation

Documentation methods

• Occurs at the time of the healthcare encounter
• Completes, accurate, and is descriptive
• Uses complete electronic documentation wherever possible

Recording documentation

• Should be accurate, concise, without bias
• Data supports the point of the analysis

Types of Nursing Assessments

• Emergency assessments focus on immediate life-threatening issues
• Focused assessments address specific patient problems
• Comprehensive assessments involve a complete history and physical exam

Emergency Assessments

• An emergency assessment focuses on life-threatening situations and determines the level of urgency based on the mnemonic ABCDE.
• Airway, Breathing, Circulation, Disability, and Exposure
• Assessments and critical interventions are performed simultaneously

Comprehensive Assessments

• Usually requires the history obtained ahead of the examination
• Data collection is achieved via discussion, reconciliation of medication, and family input

Physical Examination

• Head-to-toe format including evaluations
• A physical examination may include the skin, head, neck, eyes, ears, nose, throat, thorax, lungs, heart, blood vessels, abdomen, & neurological systems
• Genital assessments are optional

Focused Assessments

• A focused assessment targets a specific health issue
• Includes health history and physical evaluations

Clinical Reasoning and Judgment

• The outcome of a heath assessment is a portrait of a patient's physical status, strengths and weaknesses, abilities, support systems, health beliefs
• The nurse must look at heath problems and lack of resources for insight
• Nurses should be aware of subtle changes and monitor the patient in order to detect cues
• Critical implementation requires appropriate interventions

Data Organization

• Data is organized in order of most important or active findings
• Data is clustered by body system
• Data can be clustered by e.g. gas exchange, perfusion, mobility

Analyze Data

• Analyze data for findings that are expected as well as abnormal findings
• A problem list should be generated and updated as the patient's condition changes
• Involves interpretation based on experience