Health Assessment: Nursing Fundamentals

Introduction to Health Assessment

• Nursing involves constant observation and information collection for nursing judgments.
• Whether in a hospital, clinic, home, or long-term care facility, nursing assessments are relevant.
• These assessments occur informally every day.
• Nursing assessments on patients, families, or communities impact health status, be it directly or indirectly.

Nursing

Nursing involves:

• The protection, promotion, and optimization of abilities
• Illness and injury prevention
• Alleviating suffering
• Advocating for patients, families, and communities

Core Competencies in Nursing

• Institute of Medicine identified five core competencies in all areas of practice which includes:
• Centering care on the patient
• Working in interdisciplinary teams
• Using evidenced based practice
• Applying quality improvements
• Use of informatics

Diagnosis and the promotion of health

• Diagnosis and treatment relate to human responses, guided by accurate client assessments.
• Promote health and prevent illness and injury through effective nursing interventions.

Health Assessment Definition

• A systematic approach to gather and analyze patient data for planning patient-centered care.
• Nurses compare patient data with the ideal health state, considering age, gender, culture, ethnicity, and physical, psychological, and socioeconomic factors.

Patient Data

• Data gathered includes strengths, weaknesses, health problems, and deficits.
• Nurses use patient knowledge, motivation, support systems, coping ability, and preferences to develop care plans that help patients maximize their potential.

Health Assessment

• "Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings, and evaluating patient care outcomes".
• Includes a health history and physical assessment.

The Nursing Process

• Involves using a systematic and dynamic method to collect and analyze patient data, which is the first step for nursing care.
• Includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.

Health Assessment Data

• Data collected is dynamic and varies depending on patient conditions, health history, and current symptoms.
• In emergencies, data helps pinpoint issues and treat conditions.

Purpose of a Health Assessment

• You can evaluate outcomes
• Assessment becomes a continuous process in the nursing process
• Gain insight into a patient's current condition
• Helps establish databases for future assessments
• Identify how a patients condition is improving or worsening

Nursing Process

• A systematic approach to address and treat health difficulties.
• Framework for individual care for individuals, families, and communities.
• Patient-centered, focusing on problem-solving and enhancing strengths.

Nursing Process Stages

• Assessing the patient
• Analyzing data
• Diagnosing
• Determining outcomes
• Planning care
• Implementing
• Evaluating the process

Nursing Process Applicability

• Applicable in all stages of the lifespan and in all settings.
• Key steps include assessing, analyzing, diagnosing, planning, implementing, and evaluating.

Importance of Health Assessment

• First and most critical phase of the nursing process.
• Inadequate or inaccurate data leads to incorrect judgments, affecting diagnosis, planning, implementation, and evaluation.
• Assessment is ongoing and continuous throughout all phases.

Health Assessment Components

• More than just gathering information about a client's health
• Involves analyzing and synthesizing data, judging nursing intervention effectiveness, and evaluating client outcomes.
• The Nursing process is circular, not linear

Key Steps

• Conducting a health history
• Performing a physical examination
• Reviewing health record data
• Documenting findings

Data Analysis

• Leads to data analysis and interpretation, for a patient-centered care plan.
• The amount of information and extent of a physical examination depends on the setting, situation, and patient needs.

Health History

• Consists of subjective data from an interview
• Includes information about current health, medications, illnesses, surgeries, family history, psychosocial factors, and systems review.
• Patients may report feelings or experiences relating to health problems.

Subjective Patient Data

• Patient reports are called symptoms and are seen as subjective data.
• Subjective data acquired directly from patient are a primary source and if acquired from another person it is a secondary source.

Physical Examination

• Collecting objective data, referred to as signs.
• Objective data are collected using inspection, palpation, percussion, and auscultation techniques.
• Height, weight, blood pressure, temperature, pulse rate, respiratory rate, and oxygen saturation are measured.

Data Documentation

• Health assessment data is recorded at the encounter, which is available to other health professionals.
• Complete, accurate, and descriptive documentation improves care and prevents patients from repeating information.
• The health record is the legal permanent record of the patients health
• Documentation provides the baseline for changes/decisions
• Varies from agency to agency, but electronic health record is most widely used.
• It is used by health care professionals and includes data on history, examination, tests, and procedures.

Data Documentation Principles

• The basic underlying principles of documentation require data to be recorded accurately, concisely, without bias or opinion, and the point of care.

Types of Nursing Assessments

Three common types:

• Emergency
• Comprehensive
• Focused

Emergency and Urgent Assessments

• For life-threatening or unstable situations like critical injuries.
• Use triage and the mnemonic ABCDE, you must determine the level of urgency -A-Airway( with cervical spine protection is injury is suspected) -B-Breathing( rate and depth) -C-Circulation(Pulse rate and rhythm) -D-Disability-level of consciousness, pupils, movement -E-Exposure
• Assessments and critical interventions occur simultaneously.

Comprehensive assessment

• Includes history and physical assessment.
• Family history of illness, personal history of allillness, and surgeries are obtained, which are then discussed with the patients.
• You must clarify if there are any unclear areas.
• You must note the dates of diagnoses and treatments

Comprehensive History

• Includes perception of health, strengths, risk factors, functional abilities, coping methods, and support systems.
• It's important to reconcile the medication list.
• If patients can't participate, use secondary data sources like family members.

Comprehensive Physical Examination

• Assesses all body systems and is usually head-to-toe.
• This includes an assessment of the skin; head and neck; eyes; ears, nose, mouth, and throat; thorax and lungs; heart and neck blood vessels; arms and legs; breasts;abdomen; musculoskeletal; and neurologic systems.
• Rectal and genital assessments are optional.

Focused Assessment

• Based on the patient's particular health issues.
• Occurs in all settings, involving one or two body systems.
• Smaller in scope but more in-depth compared to a comprehensive assessment.

Focused Assessment Example

• A patient presents to the clinic with a cough.
• The health history focuses on the cough's duration, related symptoms (wheezing/shortness of breath), and factors affecting it.
• The physical assessment includes evaluation of the nose/throat, and chest.

Outcome of Health Assessment

• Is a portrait of a patient’s physical status, strengths and weaknesses, abilities, support systems, health beliefs, and activities to maintain health in addition to heath problems and lack of resources for maintaining health.
• The nurse analyzes and interprets these data to determine the best course of action for a plan of care.
• Physical assessment is not to be approached as just a task to be completed.

Recognition by Nurses

• Health assessment is the ongoing monitoring for any changes
• Early recognition of cues by a nurse
• Indicates a change in a patient’s health status and a deteriorating status, requires detection and appropriate interventions.

Data Organization

• After collecting and documenting data, nurses organize or cluster them so the problems appear more clearly.
• This may be done based on a body system format (e.g., cardiovascular, musculoskeletal, auditory, visual) or a conceptual format (e.g., gas exchange, perfusion, mobility).

Analysing Data

• Analyzing data is used to determine abnormal findings.
• Problems experienced need to be identified by patients and the appropriate plan of care must be set.
• Includes the formulation of a problem list which is a summary of health problems, identified as a result of the health assessment process.
• The list is typically placed in order of the most important or most active problems first, followed by problems of less concern.

Clinical Judgement

• 'an interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response.'
• Is influenced by nurses assessment data.

Clinical Judgment

• Clinical judgment depends on nurses assessment data
• Influenced by nurse’s knowledge, attitudes, and perspectives.

Priority Setting

• You must determine priorities using clinical experience, expertise, and judgement
• Prioritizing may be different for expert nurses

Priority Actions

• Life-threatening issues always must take priority, for example, circulation, airway, and breathing, over elevated temperature.
• Another example of a situation that requires immediate attention is a patient at risk for human violence or suicide.
• Your priority is to focus on stable issues and the patients needs

Assessment Frequency

• Varies on the patient's needs, purpose of data collection, and health care setting.
• Assessments vary depending on the settings , ex: long-term facilities perform them once a month and long term do them once per shift
• Vital signs and assessments should be done more often in intensive care
• A facility’s standard of care prescribes(minimum frequency.