NUR111 Health Assessment: Introduction

• Introduction to Health Assessment is a lecture for NUR111-Health Assessment.
• The lecturer for this material is Asst. Prof. Gizem Yağmur Yalçın

Introduction to Health Assessment in Nursing

• A professional nurse constantly observes situations and collects data to make nursing judgments.
• This process takes place in any setting, including hospitals, clinics, homes, and communities, or long-term care facilities.
• Nurses conduct many informal assessments daily.
• Nursing assessments made on patients, families, and communities affect nursing interventions, whether indirectly or directly influencing health.

Nursing Objectives

• The protection, promotion, and optimization of health and abilities for patients
• Prevention of illness and injury is another objective of nursing.
• Alleviation of suffering through the diagnosis and treatment of human responses
• Advocacy in the care of individuals, families, and communities

Five Core Competencies

• Five core competencies exist, identified by the Institute, demonstrating practice in all areas.

• These include providing patient-centered care, collaborating in interdisciplinary teams, evidenced-based practice, applying quality improvements, and health informatics.

• Diagnosis and treatment of human responses are determined, based on accurate client assessments, including how effective nursing interventions are to promote health and prevent illness.

Health Assessment

• Involves a systematic way of collecting and analyzing data for planning patient-centered care.
• Nurses collect health data from patients, comparing it with an ideal state, considering age, gender, culture, ethnicity, as well as physical, psychological, and socioeconomic status.
• Data about a patient's strengths, weaknesses, problems, and deficits are identified.
• Nurses incorporate patient knowledge, motivation, support systems, coping abilities, and preferences for care, to maximize a patient's potential.
• Defined as gathering information on health status, analyzing and synthesizing data, making judgments on interventions based on findings, and evaluating care outcomes
• Involves both a health history and physical assessment

Health Assessment in Nursing

• A nurse uses a systematic, dynamic process to collect and analyze patient data as a first step.

• Assessment includes physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.

• Collected data vary depending on the seriousness of a patient's condition, history, and current symptoms

• In an emergency, information is gathered to pinpoint issues and treat current conditions.

Health Assessment Performance

• Is performed to establish a database against current and future assessment measurements
• This helps to determine patterns and trends so nurses can determine if conditions are improving or worsening.
• One piece of data shouldn't be isolated, it should be related logically, and any interventions may be indicated.
• Outcomes are evaluated to make assessments a continuous part of the nursing process.

Nursing Process

• A systematic problem-solving approach to identifying and treating human responses to health difficulties
• It is the framework for individualized care for individuals, families, and communities.
• Patient-centered, focuses on problem-solving and enhancing strengths.
• The nursing process is applicable to patients at all stages of life and in all settings.

Nursing Process steps

• Assessing the patient and evaluating the patient's status to determine whether interventions were effective
• Diagnosing by analyzing data
• Making nursing diagnoses
• Planning the care to determine patient outcomes
• Making interventions

American Nurses Association (ANA) Standards of Practice

• The first six standards are based on the nursing process.
• The assessment phase is most critical in the nursing process.
• Inadequate or inaccurate data collection may adversely affect the remaining phases diagnosis, planning, implementing, and evaluating.
• Assessment is ongoing and continuous throughout the process.
• Health assessment is also analyzing, synthesizing data, and making judgments on nursing interventions.
• The nursing process is circular, not linear.

Components of health assessment include:

• Conducting a health history
• Performing a physical examination
• Reviewing data from health records
• Documenting the findings

Data analysis and interpretation

• Steps lead to data interpretation allowing a patient-centered plan of care to be implemented.
• The information amount collected varies with the setting, situation, and patient's needs.

Health History

• Reconcile medications; don't ignore them
• A health history consists of subjective data from an interview, including the patient's current health, medications, illnesses, surgeries, family, and psychosocial history, and a review of systems.
• Patients report feelings on health problems.
• Considered subjective data, patient reports are also called symptoms.
• Symptoms and primary data come directly from a patient
• Secondary data and the patient's family are obtained from another, separate person.

Physical Examination

• Collecting objective data (signs) through inspection, palpation, percussion, and auscultation
• Measurements may include the patient's height, weight, blood pressure, temperature, pulse, respiratory rate, and oxygen saturation.

Documentation of Data

• Health data is documented at the time of the encounter so other professionals involved in care can view it.

• Documentation should be complete, accurate, and descriptive, preventing multiple repetitions of patient information.

• A health record serves as the permanent legal record of the patient's health.

• Serves as baseline for subsequent changes for related care.

• The format varies from agency to agency, but electronic records are most commonly used.

• EHRs contain all individual care data including, physical examinations, history, lab results, diagnostic test, and surgical procedures.

• The goal is to have one EHR for any single patient in all health facilities.

• Underlying documentation principles require data to be recorded accurately, concisely, without bias.

Types of Nursing Assessments

• Emergency, comprehensive, and focused are three common types.
• Emergency and focused assessments address immediate and high-priority problems.
• Comprehensive assessments are broad and complete.
• The information type and amount depends on the patient's needs, purpose of collecting data, health care setting, and the nurse's role.

Emergency and Urgent Assessment

• This assessment involves life-threatening situations, like critical traumatic injury.
• Triage is used to determine urgency according to the mnemonic ABCDE i.e. Airway, Breathing, Circulation, Disability, and Exposure
• Critical interventions and assessments are performed simultaneously.

Comprehensive Assessment

• A complete history and physical assessment

• Clinics obtain patient history by filling out forms with family history, illnesses, surgeries, and medical treatments.

• Patient information needs to be discussed for clarification purposes.

• Dates and treatments are noted along with reasons for medications given such as heart medication for high blood pressure.

• A history should include a patient's perception, strengths, risk factors, abilities, coping methods, and support systems.

• Nurses need to reconcile the patient's medication list.

• If the patient can't participate in data collection, secondary resources may be needed.

• Physical exams include skin, head, neck, eyes, ears, nose, mouth, thorax, lungs, heart, neck, arms legs, breasts, abdomen, musculoskeletal, and neurological systems

• Rectal and genital assessments are optional.

Focused Assessment

• Based on patient's health issues, occurring across all settings.
• Engages one or two body systems, and the comprehensive assessment is more in-depth on specific issues.
• A patient presents with a cough, like a cough.
• Health history focuses on cough duration, symptoms, wheezing, shortness of breath, or anything that relieves or worsens the cough.
• A physical assessment includes the eval nose, throat, lungs, and sputum.

Clinical Reasoning and Judgement

• An outcome of a health assessment is a patient portrait showing the patient's health status, strengths, weaknesses, abilities, support, beliefs, resources, and problems.
• Nurses interpret data to determine the best action for a plan of care.
• Physical assessment should be completed and not considered complete as just another task.
• The meaningful data actively benefits a patient if it is applied as a purposeful way
• Health assessment is an ongoing monitoring for subtle changes by noting and knowing signs of deterioration.
• Early recognition by a nurse indicates a patient's changing health status is key to initiating interventional improvements

Data Organization

• Collecting and documenting allows nurses to organize based on severity
• Using a body system or conceptual list

Data Analysis and Interpretation

• Data is analyzed to determine what is abnormal or expected findings.
• Analysis helps the nurse identify problems experienced by patients.
• Developing a problem formulation for the health analysis
• The list is typically placed in problem severity
• Problem lists are updated as conditions change or clear

Clinical Judgement

• Defined as one's interpretation or conclusion about a patient's problems
• It is influenced by one's need, or health problems and needs the decision to choose new approaches
• Clinical judgment depends on having assessment tools
• Clinical judgment is influenced by experiences, knowledge, attitudes, and perspectives

Priority Setting

• Important for professional practice use experience and judgment
• Life-threatening issues are first: circulation, airway, and breathing
• Suicidal patients, or domestic abuse concerns are second to address
• If the issue if stable the patient's needs are first

Frequency of Assessment

• Varies with the patient's needs, collection, or setting.
• Long-term patients have monthly assessments
• Acute patients have one per shift
• ICU patients can be hourly, or less
• Standards for each facility or unit determine the requirements