Introduction to Health Assessment

Introduction to Health Assessment

• Professional nurses observe situations and collect data to make informed nursing judgments.
• This data collection occurs in various settings, including hospitals, clinics, homes, and long-term care facilities.
• Nurses conduct informal assessments daily.
• Professional nursing assessments determine interventions, directly or indirectly influencing a patient's health.
• Nursing aims to protect, promote, and optimize health and abilities.
• Nursing includes preventing illness and injury.
• Nursing focuses on alleviating suffering through diagnosis and treatment
• Nursing advocates for individuals, families, and communities.
• The Institute has identified five core competencies, including patient-centered care.
• Working in interdisciplinary teams is a core competency
• Evidence-based practice and applying quality improvements are essential competencies
• Using informatics contributes to core competencies
• Care is patient-centered and involves diagnosing and treating human responses.
• Accurate client assessments are based on promoting health and preventing illness/injury.
• Health assessment: a systematic method to collect and analyze data for patient-centered care planning.
• Nurses gather health data and compare it with ideal health, considering age, gender, culture, ethnicity, physical, psychological, and socioeconomic status.
• Patient data identifies strengths, weaknesses, health problems, and deficits.
• The nurse considers patient knowledge, motivation, support system, coping ability, and preferences to develop a care plan that maximizes patient potential.

What is Health Assessment

• Health assessment involves gathering, analyzing, and synthesizing patient information to make judgments about nursing interventions and evaluate patient care outcomes.
• A health assessment includes both a health history and a physical assessment.
• Nurses use a systematic, dynamic approach to collecting and analyzing patient data as a first step in care.
• Assessments include not only physiological data but also psychological, sociocultural, spiritual, economic, and lifestyle factors.
• Data collected during the physical assessment depends on the seriousness of a patient's condition, health history, and current symptoms.
• Emergency assessments pinpoint issues and treat conditions.
• Health assessments establish a database for measuring future assessments
• Health assessments identify patterns and trends to determine if the patient's condition is improving or worsening.
• Instead of using one piece of data in isolation, you think logically to analyze how data are related and what interventions may be indicated.
• Can evaluate outcomes and becomes a continuous part of the nursing process

Nursing Process

• A systematic approach is used to identify and treat human responses to potential health difficulties.
• Provides a framework for individualized care for both the individual and their community.
• Focuses on solving problems and enhancing strengths.
• Nursing process is applicable, no matter what stage of life or setting the patient is in.
• It includes assessing the patient, analyzing data, making nursing diagnoses, planning care, implementing interventions, and evaluating outcomes.

Introduction to Health Assessment

• American Nurses Association (ANA) adheres to standards of practice
• The first six standards are based on the nursing process.
• Assessment is key and the most critical phase of the nursing process.
• Inadequate, inaccurate data collection leads to incorrect nursing judgements which adversely impacts remaining phases.
• Assessment is an ongoing, continuous part of the nursing process.
• It is more than just gathering information about the client's health status.
• It involves analyzing and synthesizing data to judge the effectiveness of interventions and evaluate client care outcomes.
• The nursing process is circular, not linear.

Components of Health Assessment

• Conducting a health history, performing a physical examination, reviewing data, and documenting findings are the components of a health assessment.
• The steps lead to data analysis and interpretation, which leads to a patient-centered plan of care.
• The amount of information depends on setting/situation and patient need.

Components of Health Assessment Overview

• Health assessment is an holistic approach encompassing a health history, examination, data review and documentation.
• A health history involves collecting subjective data through interviews, including information about the patient's current health, medications, illnesses, family history, psychosocial factors, and systems review.
• Physical examinations collect objective data through inspection, palpation, percussion, and auscultation, measuring height, weight, blood pressure, temperature, pulse rate, respiratory rate, and oxygen saturation.
• Documentation, including legal health records, serves as a baseline.
• Accurate and complete documentation improves care and prevents patients from repeating information.
• EHR is the format used in documentation
• Basic principles require data to be recorded accurately, concisely, without bias.

Health History

• A health history involves collecting subjective data during an interview.
• It includes current health state, medications, illnesses, surgeries, family/psychosocial history, and review of systems.
• Patients report feelings/experiences related to health.
• Patient reports are symptoms considered subjective data.
• Subjective data acquired from a patient is a primary source.
• Data from another person like a family member is secondary.
• Objective data is observed, felt, heard, or measured.
• Subjective data is perceived and reported by the patient.
• Some data falls in both categories.

Types of Nursing Assessments

• The three types of nursing assessments are emergency, comprehensive, and focused.
• Emergency and focused assessments address immediate/high-priority problems.
• Comprehensive assessments are thorough and complete.
• Information is variable according to data collection, needs, purpose, settings, and role.

Emergency/Urgent Assessment

• An emergency assessment handles life-threatening situations (e.g., critical traumatic injury).
• The mnemonic ABCDE triages urgency:
  • A: Airway (with cervical spine protection if injury is suspected).
  • B: Breathing (rate, depth, accessory muscles).
  • C: Circulation (pulse, rhythm, skin color).
  • D: Disability (level of consciousness, pupils, movement).
  • E: Exposure.
• Assessments and critical interventions performed at the same time.

Comprehensive Assessment

• Includes a complete health history and physical assessment.
• History may be filled out in the clinic, including family history of illness, personal history, and medical tx/surgeries.
• Discuss info with patient and review
• Dates of diagnoses and tx are noted along with the medication
• It addresses the patient's overall health perception including strengths, coping, and support
• Must reconcile medication list of actual meds taken
• If a patient can't participate, use secondary sources of data.
• A comprehensive physical examination covers all body systems, from head to toe, including optional rectal and genital assessments.

Focused Assessment

• This type of assessment is based on the patient’s specific health issues and occurs in various settings.
• More in-depth than the comprehensive assessment, but it is smaller in scope and usually involves one or two body systems.
• One example is a cough, where the health history focuses on duration, symptoms, causes, etc.
• Evaluation includes the nose, throat, lungs, and if there is septum.

Clinical Reasoning and Judgment

• The outcome of a health assessment is a portrait of a patient's physical status, strengths, weaknesses, abilities, support systems, health beliefs, the lack of resources, and activities to maintain health.
• Nurses analyze and interpret data to find the best treatment
• Physical assessment should not be approached as a task
• There should be an indication of change which is central to early intervention
• Data collection without an integrating purpose does little benefit the patient.
• Nurses should be aware of slight changes of deteriorating status and initiate appropriate interventions.

Data Organization

• After collection/documentation you should organize and cluster information
• Organizing/clustering helps identify problems more clearly.
• It is based on body systems (cardiovascular, musculoskeletal etc) or conceptual data
• Organizing/clustering is also based on system, time, and body

Data Analysis, Interpretation, and Developing a Problem List

• Data is analyzed to determine normal and abnormal findings.
• Analysis helps nurses initiate a care plan for the issue
• The problem list is a summary of health problems after the analysis
• The list is ordered by the severity/importance
• It is updated as the patient changed or resolves.

Clinical Judgement

• An interpretation/conclusion about a patient's needs, problems, or concerns; a decision to improvise, modify standard approaches, or not act at all.
• Although the nurse's clinical judgment depends on an accurate data collection, data helps direct nursing actions.
• Experience, knowledge, attitudes, and the nurse's perspectives shape clinical judgment.

Priority Setting

• An important skill of professional nursing
• It is challenging to learn
• Based on clinical experience, knowledge, expertise, and judgement
• Expert nurses prioritize differently
• Life threatening issues have priority: breathing, circulation, airway, etc.
• Human violence and suicide
• If the patient is stable, focus on issues with high importance or concerns.

Frequency of Assessment

• Varies with patient's needs, purpose of data, and setting
• Long term facility gets a monthly assessment
• Acute setting: assessment per shift
• Intensive care: vital signs are assessed hourly
• Facility standards prescribe minimal frequencies.