Health Assessment in Nursing

Introduction to Health Assessment in Nursing

• Nursing is vital for protecting, promoting, and optimizing patient health and abilities
• Nursing is also important for preventing illness and injury and advocating for individuals, families, and communities
• The five core competencies are providing patient-centered care, working in interdisciplinary teams, using evidenced-based practice, applying quality improvements, and utilizing informatics
• Core patient needs must always be the focus
• Health assessment is a systematic method of collecting and analyzing data for planning patient-centered care
• To determine a patient's ideal state of health, nurses collect health data, considering factors like age, gender, culture, physical, psychological, and socioeconomic status
• Patient strengths, weaknesses, health problems, and deficits are identified
• Nurses design care plans that maximize a patient's potential by incorporating their knowledge, motivation, support systems, coping abilities, and preferences
• Health assessment process is implemented in every part of the job from the hospital to at home patient care

What is Health Assessment?

• Health Assessment involves gathering patient data, analyzing it, and making informed decisions about nursing interventions and patient care outcomes
• Nurses use a systematic process to collect and analyze patient data as first step needed for delivering nursing care
• This process is dynamic and holistic
• Assessment includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors
• The data collected dynamically varies depending on the patient's condition, medical history, and current symptoms
• In emergencies, information to pinpoint the source of issues and treat current conditions is collected

Health Assessments

• Health assessments can provide insight, establish a database, identify trends, and evaluate outcomes for the patient
• A health assessment needs consistent evaluation for it to be effective

Nursing Process

• The nursing process is a systematic method for addressing health issues

• It includes:

• Assessment: Nurses collect data to organize into a database

• Diagnosis: Analyzing data

• Determining Outcomes: determining a care plan to achieve specific goals

• planning

• Implementation: Putting the care plan into action

• Ongoing evaluation: Is crucial for adjustments

• The nursing process is applicable in all life stages and settings

Application of the Nursing Process

• The nursing process involves assessment, diagnosis, outcome identification, planning, implementation, and evaluation
• Documenting data is an important component of health assessment

Introduction to Health Assessment

• The American Nurses Association (ANA) sets standards of practice
• The first six standards are built on the nursing process
• Assessment is the most critical phase in the nursing process.
• Accurate judgements depend on effective data collection for effective and complete diagnoses
• While assessment begins early, it is ongoing throughout the process
• Health assessment involves gathering information and synthesizing data to inform effective nursing interventions
• It should be viewed as a circular process rather than linear

Components of Health Assessment

• Components include conducting a health history, performing a physical examination, reviewing health records, and then documenting the findings, and interpreting the need
• The data must be documented and reachable by other healthcare professionals
• Collecting and interpreting data creates a patient-centered plan
• The depth of data collected depends on the needs of the patient and care environment
• Health assessment is viewed holistically, requiring a complete and diverse approach

Health History

• A health history collects subjective data during an interview
• It contains data about the patient's current health, medications, past illnesses/surgeries, family/psychosocial background, and a review of systems
• Patients may share feelings or experiences in regards to health problems
• Subjective data is acquired directly from a patient and is considered the primary source for data
• Data from other sources such as family is classified as secondary
• Signs are objective observations, while symptoms are subjective experiences reported

Physical Examination

• A physical examination involves collecting verifiable, objective data
• During a physical examination, objective data are collected using the techniques of inspection, palpation, percussion, and auscultation
• A patient's height, weight, blood pressure, temperature, pulse rate, respiratory rate, and oxygen saturation are measured

Documentation of Data

• Health assessment data should be recorded during the encounter, and made available to other health professionals
• Documentation that are detailed, thorough, accurate, improve care and can prevent the patient from having to restate the same information
• Health records serve as the legal, permanent record
• The health record is an important tool for evaluating change and care decisions
• Electronic health records maintained by the health providers are widely used
• Documentation data should be accurate, concise, unbiased, and focused on the point of care
• All health professionals in an individuals care should use the documentation system

Nursing Assessments

• Common nursing assessments are emergency, comprehensive and focused
• The amount and type collected information varies based on data, healthcare setting etc.
• In an emergency situation the focused assessment will be about the first and biggest priority

Emergency and Urgent Assessments

• Emergency assessments respond to life threatening issues
• Triage determines urgency and uses the mnemonic ABCDE where:
• A is Airway
• B is Breathing
• C is circulation
• D is disability
• E is exposure

Comprehensive Assessment

• Comprehensive assessments include health history and physical assessment
• The patient initially fills out the assessment themselves
• Clarify areas and then discuss the data with the patient
• It should also include the patient's perception on health, support, and coping mechanisms
• Any secondary data sources such as family should be used for data collection

Focused Assessment

• Focused assessments focus on a specific health issue
• This type of assessment can be carried out any where and is typically focused on only a few body parts
• Example: A patient with a cough. The cough in question is a main priority for assessment.

Clinical Reasoning and Judgement

• Assess and manage a portrait of a patients physical status, mental state, and support structure
• Determine data through data analysis for best results of the care plan
• Physical assessment is important. Do not just do it carelessly
• Integrate the information in a way that has proper benefits to the patient

Ongoing Clinical Reasoning and Judgement

• Health assessment makes sure to monitor a patient's condition
• There must be awareness of early signs of any deterioration of a patient's status
• There should be appropriate interventions to make sure patient's stay on the right path

###Data Organization

• Data should be clustered together so problems are easily identified
• This can be body system, or a conceptual formation like mobility and gas exchange

Problem List

• Data must be identified in a problem list
• It must be sorted of the most important and least important problems
• Data updates as patients' conditions change

Clinical Judgement

• The term 'clinical judgment' involves the care and process in how to take action on the issue
• Judgements is improved with the more care given and assessment

Priority Setting

• Priority setting is an important and challenging skill in nursing that:
• Uses clinical experience
• Requires using clinical judgement to prioritize the health process
• Assumes all factors are involved
• Issues that are considered life threatening take priority, like circulation, airways or breathing.
• If those problems are stabilized, you prioritize the goals the patient wants and spending more time with them become more important

Frequency of Assessment

• How often and when you decide to assess something varies with patient needs

• Considerations:

• Health Setting

• Hospital Care

• Long term patients

• Critical situations where patients must have vital signs checked to see if interventions are effective

• The facility standards must be followed