NUR111 - Intro to Health Assessment in Nursing

• Instructor: Asst. Prof. Gizem Yağmur Yalçın
• Course: NUR111-Health Assessment

Introduction to Health Assessment in Nursing

• Professional nurses constantly observe and collect information to make nursing judgments across various settings like hospitals, clinics, homes, and long-term care facilities.
• Nurses conduct informal assessments daily which influence patient health status.
• Health assessment processes apply in every area of nursing and contribute to:
  • Protecting, promoting and optimizing health and abilities.
  • Preventing illness and injury.
  • Alleviating suffering through diagnosis and treatment of human responses.
  • Advocating in the care of individuals, families, and communities.
• Institute of Medicine identified five core competencies across all areas of practice:
  • Providing patient-centered care.
  • Working in interdisciplinary teams.
  • Use of evidenced-based practices.
  • Applying quality improvements.
  • Utilize informatics.
• Nursing care should be patient-centered.
• Accurate client assessments drive diagnosis and treatment of human responses, promoting health, and preventing illnesses and injury.
• Health assessment is a method of collecting and analyzing data for planning patient-centered care.
• Nurses gather patient health data and compare it to the ideal state of health, based on age, gender, culture, ethnicity, physical and socioeconomic status.
• Patient's strengths, weaknesses, health problems, and deficits are identified.
• Nurses use patient's knowledge, motivation, support systems, coping ability, and preferences to develop a plan of care that will help the patient to maximize his or her potential.

What is Health Assessment?

• Health assessment involves gathering, analyzing, and synthesizing the data to makes judgements in order evaluate patient care outcomes
• Health assessment is a critical first step involving a method to collect and analyze data for patient care.
• Assessments include physiological, psychological, sociocultural, spiritual, economic, and lifestyle factors.
• Collecting data during physical assessments varies according to the patient's condition, health history, and current symptoms.
• In emergencies, information gathered pinpoints the source of issues for treatment.
• A health assessment can do the following:
  • To gain further insight into a patient's current condition
  • To establish a database to measure future assessments against
  • To identify patterns and trends in improving or worsening a patient's current condition
  • To use data to think logically about interventions

The Nursing Process

• Problem-solving approach to address potential health difficulties.
• Provides individualized care to individuals, families, and communities.
• Patient-centered care focused on solving problems and enhancing strengths.
• The nursing process applies to patients in all stages of life and in all settings.
• Assessment is the first and most critical phase of the nursing process.
• If data collection is inadequate, the entire the nursing process will be adversely affected
• Assessment is ongoing throughout all phases of the nursing process.

Components of Health Assessment

• Conducting a health history
• Performing a physical examination
• Reviewing other data from the health record
• Documenting the findings
• The steps lead to data analysis and interpretation for developing and implementing patient centered care plans
• The amount of information collected via a health history and physical depends on the setting, situation, and needs of the patient.

Health History

• Consists of the subjective data collected during an interview.
• This History includes information about patient’s current state, current medications, previous illnesses/surgeries, family history, personal and psychosocial history, and review of systems.
• Patients report feelings or experiences with health problems.
• Patient reports are called subjective data and symptoms
• Subjective data acquired directly is the primary source
• Data from another person is considered secondary data

Physical Examination

• Gathers objective data or signs.
• Uses inspection, palpation, percussion, and auscultation techniques.
• Measures include height, weight, blood pressure, temperature, pulse rate, respiratory rate, and oxygen saturation are measured.

Documentation of Data

• Health assessment data is documented at the time of the health care encounter
• Complete, accurate, and descriptive documentation prevents having to provide the same information to another health care provider
• A health record as the legal permanent record of health status when health care is encountered
• Documentation serves as the point to evaluate changes and decisions for care
• Electronic health record facilitates the process in a single location
• Data has to be recorded according the the principles - accurately, concisely, without bias or opinion, and the point of care

Types of Nursing Assessments

• Emergency: Centers on immediate and highest priority problem.
• Comprehensive: Broad and complete. Includes a complete health history and physical assessment
• Focused: Based on patient's health issues, occurs in all settings and has the greatest depth of insight

Emergency Assessments

• Involves a life-threatening or unstable situation; triage helps determine the level of urgency
• Airway, breathing, circulation, disability, and exposure - mnemonic "ABCDE"

Comprehension Assessments

• In a clinic setting, the medical history should have family, personal, and medication history
• After reviewing the history with a patient, one must collect dates of diagnoses and treatments, and medications

Focused Assessments

• It is the patient presenting to the clinic with a cough and the health history focusing on duration, shortness of breath and when it is relieved
• An evaluation must be assessed for nose, throat, and sputum testing

Clinical Reasoning and Judgement

• A portrait of a patient's physical status, strengths, weaknesses, abilities, support systems, health beliefs, activities and resources
• The nurse analyzes and interprets to provide an accurate and safe plan of care
• Physical assessment is not a task to be completed
• Data must be taken as a necessary step in what is provided
• Another critical, health assessment is the ongoing monitoring of subtle changes
• An evaluation is necessary to have appropriate implementation and interventional care

Data Organization

• Must use collection and documentation of data
• Nurses organize or cluster the types of problems clearly
• Can be based on body system format (cardio, muscular) or mobility format (gas exchange)

Data Analysis and Interpretation

• Information helps the physician to start a medical plan when necessary
• A key component is the formulation of a problem list
• Problems list is typically an activity or a statement
• Data collection should only be done with experience in areas with knowledge

Clinical Judgment

• Interpreting what the patient is going through, and a final description of health problems when needing to take action
• If the collection of data is inaccurate, the nursing actions will not guide
• Interpretation of data is also the influence as well
• Should be determined on the nurse's knowledge

Setting Priorities

• It's important to set your priorities during an interaction, and will be challenging to learn at first.
• It involves the nurse's experience
• Take a life-threatening issue and resolve elevated temperature in the care practice, i.e., a patient at risk must be treated as important

Regular Assessment

• Must measure with patient needs, with the measure and regular collection of data
• Long term must be monthly, or the the hospital once
• Can be evaluated hourly