NUR111 Health Assessment: Study Notes

• ISTINYE University: NUR111 Health Assessment Lecture summarised study notes

Introduction to Health Assessment in Nursing

• Professional nurses constantly observe and collect information to make well-informed nursing judgments
• Health assessment is a continuous process, regardless of the setting, be it a hospital, clinic, home, or long-term care facility
• Nurses perform multiple informal assessments daily as part of their routine practice
• Professional assessments impact nursing interventions, which impact health status

Nursing Goals

• Nursing aims to protect, promote and optimize health and abilities
• Alleviation of suffering via dignosis and treatment of human responses
• Nursing includes illness/injury prevention
• Advocacy for patient care is a key component of nursing

Core Competencies

• Competency in evidenced-based practice
• Applying quality improvements that use informatics
• Nurses should provide patient-centered care
• Function within interdisciplinary teams

Planning Patient Centered Care

• Diagnosis and treatment of human responses
• Accurate client assessments are the base for effective interventions
• Promotion of health
• Prevention of illness and injury is a goal

Health Assessment Defined

• This is a systematic method of obtaining and analyzing patient data for patient-centered care
• Nurses collect patient data and compare it to benchmarks, considering age, gender, culture, ethnicity, and other factors
• Identifying strengthens, weaknesses, health problems and deficits
• This information helps nurses develop tailored care plans that supports patients to maximize potential

What Constitutes A Health Assessment

• Gathering data about the health status of the patient, and analysing it to inform judgement on care outcomes.
• Relies on a health history and physical assessment

Key Aspects of Health Assessment

• Utilises a systematic, dynamic approach to collect and analyze data
• Serves as the first step in the delivery of nursing care
• Considers physiological data, but also a patients psycological, sociocultural, spiritual, economic and lifestyle factors

Factors Influencing Assessment Data

• Patient historical health records
• Lifestyle factors
• Current symptoms
• Nutrition
• Development
• Mental health
• Culture
• Safety issues
• Data collected differs, according to the seriousness of the patients condition

Purpose of Health Assessment

• Enables further deeper insight of the patients current condition
• Establishes a baseline for future assessments and helps identify patterns and trends
• Determine if patients status is improving or worsening

Nursing Process Overview

• Systematic problem-solving approach to identifying and treating potential health difficulties
• Provides a framework for individualized care for patients, families, and communities
• Patient-centered, problem-solving, and strength-enhancing approach
• Collection of data
• Analyzing data
• Diagnosing
• Determining outcomes
• Implementing a plan of care
• Evalutating outcomes

Nursing Process Applicability

• The nursing process is applicable to all patients at all life stages
• Continually evaluates weather medical interventions are effective
• Data analysis is key

Documentation During Nursing Process

• Includes health history and physical examinations
• Includes assessments
• Includes diagnosis
• Evaluation of all components

ANA Standards

• American Nurses Association (ANA) Standards of Practice and the nursing process are heavily based on these standards which includes collecting subjective and objective data

Key Aspects of The Assessment Phase

• Assessment is the most important and critical part of the nursing process
• It is an ongoing and continuous element when caring for a patient

Health Assessment

• Must include analysis and evaluation of client care outcomes
• Not a linear process, but circular

Components of Health Assessment

• Taking a health history
• Doing a physical examination
• Reviewing other data
• Documenting the findings

Data Analysis and Interpretation

• Must lead to data driven patient care that is well planned and implemented
• The more information the better
• All information is dependent of certain factors

Holistic Health Assessment

• Should incorporate:
• Collect health history
• Review other data the patients personal health record
• Analyas and interpret data
• Development of a plan of care

Health History

• Subjective data collected during an interview
• Includes but not limited to
• Current state
• Medications
• Illnesses
• Surgeries
• Patients feelings towards their own experience

Subjective Data

• Patient reports via symptoms
• If a patient acquires data directly, it it considered a primary source
• Data from another person is considered a secondary source

Physical Examination

• Objective data collected, sometimes referred to as "signs'
• Examples techniques are: Inspection, palpation, percussion, and auscultation (temperature, pulse rate, respiratory rate, and oxygen)

Documenting Findings

• Must be thorough but concise
• Data must be recorded accurately and unbiased for continuity of future treatment
• Information must be accurate, complete, and descriptive
• Should accurately provide all heath records that prevents miscommunication

Documentation of Data Requirements

• A legal permanent record of patients status
• Baseline data analysis for review and changes, and future treatments
• Electronic records are standard, because digital data is easily maintained
• Should effects knowledge

Types of Nursing Assessments

• Three common assessment types include emergency, comprehensive, and focused
• The data gathered should be based on the health care setting
• Emergency and Focused assessments center on the most important patients, and the highest priority promblem
• Comprehensivr essessments are broad and inclusive

Emergency and Urgent Assessment

• Used when potentially dealing with a life threatening injury
• The level of urgency should be measured to A, B, C, D, E
• Airway
• Breathing
• Circulation
• Disability
• Exposure
• Assessments and interventions should happen simultaneously

Comprehensive Assessment

• Involves both history and physical assessments
• Any information should be discussed with patients
• Dates of diagonosis and reasons behind any treatments that exist should be mentioned.
• Must reconcile all medication
• Secondary sources such as patient family members are important if the patient is unable to proceed

Physical Examinations

• Should use full medical and surgical history for a patients complete assessment
• Exam includes:
• assessemnt from head to toe
• assessemnt of skin
• assessemnt of head and neck and eyes
• assessemnt of ears nose, mouth,throat
• assessemnt of thorax lung,heart, abdomen, musculoskeletal, and neurologic systems
• should assess mental status
• Genital/Rectal test are optional

Focused Assessment

• Deals with specific medical issues
• smaller in scope than a comprehensive assessment, but broader in depth

Clinical Reasoning and Judgement

• Outcome must present complete picture of patient status
• Nurse must conduct treatment
• All information must be used appropriately

Key Components of Health and Treatment

• Must have clear indications of changes in patients health
• Early actions and appropriate interventions

Organization

• After collecting and documenting, organize and cluster your data

Data Analysis and Problem List

• Determine findings that can be normal or abnormal
• Nurse must then identify problems and make a plan
• List should contain accurate summary of all health problems
• All lists are updated with the patients condition

Clinical Judgement Requirements

• Should be about conclusion and interoperation
• Must use new practices as applicable
• Data must be accurate to have proper actions

Determining Priority

• Priorities must be based with clinical expertise and experience
• Is an essential part of treating a patient
• Must be familiar with violence and potential suicide
• Priorities may change, depending on the patients individual concerns

Frequency of Assessment

• May change on
• patients medical condition
• Data collection
• Health care settings
• Should identify standards within each unit and facility
• Time scales of long term care settings may be different than those of hospital settings