Health Assessment NRCM0 101

Nurse’s Role in Health Assessment

• Nurses play an expanding role in health assessment within healthcare settings.
• Complete nursing health assessments involve systematic head-to-toe examinations.
• Assessment relies on self-reported symptoms, observations, health histories, and physical examinations.
• Nurses maintain 24-hour oversight of patients, documenting statuses through Nurses’ Notes.

Nursing Process

• Defined as a systematic, rational method for planning and delivering nursing care.
• The goal is to identify health statuses and problems, establish care plans, and provide specific interventions.
• Five phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Phases of the Nursing Process

• Assessment: Gathering subjective and objective data, including medical, surgical, family, and psychosocial histories.
• Diagnosis: Formulation of nursing diagnoses through clinical judgment to identify patient issues.
• Planning: Setting individualized goals and outcomes tailored to the patient’s needs.
• Implementation: Performing specified nursing tasks and interventions.
• Evaluation: Assessing whether the interventions were successful or not.

Health Assessment

• An organized approach to appraise health factors relevant to clients.
• Combines subjective data from interviews and objective data from physical examinations.
• Conducted during admission, health camps, discharges, and follow-ups.

Purpose of Health Assessment

• Establishes a database of normal abilities, risk factors, and functional changes.
• Aids in identifying causes of diseases and determining necessary treatments.
• Supports medical research and helps identify clients' strengths, weaknesses, motivations, and coping skills.

Principles of Health Assessment

• Accurate assessments are foundational for nursing care and interventions.
• Comprehensive approaches should include data collection, documentation, and evaluations.
• Documentation must be objective, clear, and timely.
• Confidentiality of collected information is crucial.

Types of Assessment

• Initial Comprehensive Assessment: Conducted on admission for baseline health data.
• Ongoing or Partial Assessment: Follow-up data collection after initial assessments.
• Focused or Problem-Oriented Assessment: Detailed examination of specific health issues.
• Emergency Assessment: Rapid assessments in life-threatening situations, focusing on critical bodily functions.
• Time-Lapsed Assessment: Comparison of current health status to previously collected baseline data.

ABCDE Assessment in Emergencies

• A: Airway
• B: Breathing
• C: Circulation
• D: Disability
• E: Exposure
• Prioritizes life-threatening issues in order, enabling timely interventions.

Assessment Skills

• Observation: Utilizes all senses to assess the patient and involves more than just sight.
• Interview: Planned interactions aimed at gathering information and understanding patient concerns.
• Physical Examination: Systematic approach employing senses to detect health issues.
• Intuition: Use of clinical experience and insight for rapid decision-making in ambiguous situations.

Assessment Process

• Involves collecting, organizing, validating, and documenting data.
• Sources of Data:
  • Primary: Directly from the patient via interviews and examinations.
  • Secondary: From family, medical records, and other healthcare providers.

Types of Data

• Subjective Data: Symptoms reported by the patient (e.g., feelings of nausea).
• Objective Data: Observable and measurable signs (e.g., temperature readings).

Review of Subjective vs. Objective Data

• Subjective examples: Headaches, toothaches, personal statements about health.
• Objective examples: Recorded temperature, respiratory rates, and observable signs like cyanosis.