Nurse's Role in Health Assessment

LESSON 1: THE NURSE'S ROLE IN HEALTH ASSESSMENT

• The nursing process includes assessment, diagnosis, planning, implementation, and evaluation.
• The assessment phase involves collecting subjective and objective data.
• The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment
• Planning involves determining outcome criteria and developing a plan.
• Implementation involves carrying out the plan.
• Evaluation involves assessing if outcome criteria have been met and revising the plan as necessary.
• Assessment is the first and most critical phase which involves collecting subjective and objective data
• Incomplete assessments may lead to inadequate or inaccurate clinical judgments.
• The assessment phase is ongoing and continuous phases
• Assessment is more than just gathering information
• Physical medical assessments primarily focus on the client's physiologic development status.
• Holistic nursing assessments collect subjective and objective data to determine a client's overall level of functioning
• Mind, body, and spirit are interdependent factors that affect each client's level of health.
• There are valid nursing assessment framework methods available.
• The four basic sections of health assessment: history of present health concern, personal health history, family history, lifestyle and health practices.
• "Evidence-Based Health Promotion and Disease Prevention", Healthy People 2030, and other tools are available to screen clients for potential health risks.
• USPSTF stands for risk versus benefit in screenings.
• Initial comprehensive assessments include subjective data, past health history, family history, and lifestyle and health practices.
• Ongoing or partial assessments continue data collection after a comprehensive assessment, provide a mini overview, and reassess any problems.
• Focused or problem-oriented assessments do not replace comprehensive assessments, include a thorough assessment of the particular client problem.
• Emergency assessments are rapid assessments in life-threatening situations to provide prompt treatment and prevent death.
• Four major steps of health assessment: collection of subjective data, collection of objective data, validation of data, and documentation of data.
• These steps tend to overlap and can be performed concurrently.
• Preparing for the assessment involves: Reviewing client's record and client's status with other health care team members.
• It's important educate about client's diagnosis and tests, reflect on personal feelings, organize assessment materials.
• Collecting subjective data involves gathering biographical information, history of present health concern, personal health history, family history, health and lifestyle practices, and reviewing systems.
• Collecting objective data involves assessing physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing.
• Validating assessment data is a crucial part of the process to ensure assessments are not ended before all relevant data have been collected; it can help prevent documentation of inaccurate data.
• Documenting data forms the database for the entire nursing process, provided data for all other members of the health care team, and ensures valid conclusions are made.
• Analyzing cues to identify client concerns involve identifying: abnormal and supportive cues, and clustering of cues.
• Culture, family, and community will affect each client, even if only in subtle ways.
• Must be aware of any perceived notions of yourself
• Assessment: First you collect subjective and objective data,.
• Planning: Then determine outcome criteria and develop a plan.
• Implementation: Then carry out the plan.
• Evaluation: Assess whether outcome criteria have been met and revise the plan as necessary.

LESSON 2: COLLECTING SUBJECTIVE DATA: THE INTERVIEW AND HEALTH HISTORY

• Collecting subjective data can reveal special considerations for interviewing the client, guide the nurse in obtaining necessary information and when there is no recorded info the nurse will depend on interviewing skills
• The introductory phase of interviewing includes introducing oneself, explaining the purpose of the interview, discussing question types, explaining note-taking, assuring confidentiality, ensuring comfort and privacy, and developing trust.
• The working phase of interviewing includes biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems, lifestyle and health practices, listening/observing and critical thinking.
• Nurse reviews the medical record before meeting the client in the pre introductory phase.
• This helps the nurse assess current needs, the interview is the next method.
• Listening, observing cues, and using critical thinking skills to interpret and validate information received during the interview.
• Intro consists of introducing yourself, explaining the purpose of the interview, explaining the reason for taking notes, assuring the client that confidential information will remain confidential, and making sure that the client is comfortable and has privacy.
• Verbal and non verbal skills are used to build trust and rapport.
• Summarize obtained info, validate prob and goals, identify and discuss possible plan to resolve, make sure to ask if anything else.
• Nonverbal communication includes appearance, demeanor, attitude, silence, and listening.
• Avoid excessive or insufficient eye contact, distraction, and standing as nonverbal communication.
• Verbal communication can be open-ended questions, closed-ended questions, using laundry lists, rephrasing , use of phrases, inferring and providing information
• Verbal communication to avoid includes leading questions, rushing through the interview, or reading the questions.
• During interview be mindful of gerontologic, cultural and emotional variations
• With anxious patients, provide the client with simple, organized information in a structured format, explain your role, ask simple, concise questions, avoid anxiety like them, and decrease external stimuli.
• With angry client, approach in a calm, reassuring manner, allow venting, assist when needed, and avoid arguing or touch
• Approach depressed client with understanding, remain neutral, and avoid encouraging.
• Manipulative clients need structure and limits while differentiating between manipulation and a reasonable request.
• Setting limits can be done by setting hard limits, provide alternate methods of coping with others, and reporting inappropriate behavior to the supervisor.
• Some sensitive issues include dying, spirituality, and sexuality the nurse must allow venting, simple question, and refer if not comfortable
• With interpreter, nurse is responsible for adapting language and assisting where clarification is needed, make sure to look directly and pay close attention to make.
• A complete health history includes biographical data, reasons for seeking health care, history of present health concern, past health history, family health history, review of systems, lifestyle and health practices, and developmental level.
• Biographical Data: Name, address, phone number, gender, provider (client or other), birthday, SSN, culture and ethnicity, place of birth, nationality, and marital status.
• Reason for seeking care uses the patients words on main issue that the patient is concerned about and how do having help or concern.
• With the history of present health, it's important for answers to be descriptive, use assessment skills, insight on problem

Steps of Assessment and Objective vs Subjective Data

• Subjective: Sensations, feelings, perceptions, desires, preferences, beliefs and personal information.
• Objective: physical characteristics, body function, appearance, behaviors, measurements, lab testing.
• PQRST pain analysis mnemonic: Provocative/pallative, Quality, Read, Security, Timing
• Personal Health History: Growth, disease and immunization, allergies, medications, previous, hospitalization, surgeries, incidents, psychiatric
• Review system looks at general, head to toe: skin, eyes, ears, nose, thorax, breast
• 2. Describe a clients typical day and habits, values, work, stress levers and environmental

LESSON 3: COLLECTING OBJECTIVE DATA: PHYSICAL EXAM TECHNIQUES

• Collecting objective data uses direct observation during interaction with client, info collected by physical techniques and basic knowledge of what is needed
• Types of Equip: operation need, self and client prepping, properly perform techniques.inspection, palpitation, procession
• Collect equipment and put in place, use tools to perform efficiently
• Prep area: comfy, warm, free of interruption, proper lighting, firm table, bed side table.
• Self: address anxiety. Technique, don't spread infections.
• Care: based or risk assessment, hand washing, gloves (change as needed),
• P:skin care-wash, keep short, no nails, don;t keep rings there, etc. Respiratory hygiene/cough
• 2. approach by explaining, respect, explain, tell why
• Positioning during the exam includes: sitting, standing, supine, simms recumbent, knee-chest, lithotomy
• For adults, if too old, let them rest, small steps only
• Master 4 techniques
• inspection; vision smell hearing. Comfy temperature, lighten, view before touch
• palp consult using hand to feeling

1. size/ shape, density,

• percussion uses pain, size,
• Auscultation requites stethoscope, volume, pitch, duration. To block outside sounds, warm tip

LESSON 4: VALIDATING AND DOCUMENTING DATA

• Initial data can be identify as certain overlook
• Steps decide weather need more data
• To obtain more realize additional
• Documentation data varies on various
• Practice, accrediation
• Health care developed
• Remember its not document than it didn't happen
• Promote team work, effective process

Key Elements of Nurse Interaction

• Two key elements
• Every healthcare is unique
• Subjection and object
• Intently Document
• Guide lines
• Keep information
• Document leak
• Record clients feeling
• Record detail of symptoms
• initial, ongoing form or speciality.
• verbal include SBAR, face to face and let them validate
• Question 1: Nurse make sure data is okay
• Question 2: Nurse to fololow

LESSON 5: THINKING CRITICALLY TO ANALYZE DATA TO MAKE INFORMED CLINICAL JUDGMENTS

• Clinical judgment: diagnostic of clinical reason + identify concern
• Have knowledge: what data
• Open mind: criteria
• Check with patient.
• Step 1: Look to identify abnormal
• Step 2: list abnormal signs
• Step 3: Draw references

Thinking Critically

• To improve help ask:
• are you open minded
• Use knowledge for research and others data
• Step identify normal and support cue, also have anatomy, psychology, socialology

LESSON 6: ASSESSING MENTAL STATUS INCLUDING RISK FOR SUBSTANCE ABUSE

• Assessment help identify:
• level
• observation, communication ability
• refer as needed
• factors include economic and social violence
• changes/in structure: to deal
• Substance Abuse
• abuse may become priority
• Marijuana can be misused
• can depend on type and variety
• Mental health often essential on mental status

The Nursing Health History

• The nursing health history can allow appearance, general behavior, thought flow, processes on appropriate questions test.
• Bio can be collect and assess
• Assessment
• equipment. Need

The Nursing Assessment

• Some immigrant help test
• Level of conscious and mental status
• Cognitive ability as to what they know

Questions to ask the Patient

• Question 1: Mental health affect the body
• Question 2: Evaluatating is a key for mental
• Question 3: what is stupeous for clinet

LESSON 7: ASSESSING PSYCHOSOCIAL, COGNITIVE, AND MORAL DEVELOPMENT

• The growth and development phase is that no two is embracing to show
• Growth as a person with adding new skills while development as person improve and enhance
• Erikson theory involves both personal and outside reaction that societal will affect
• Basic Value which help the other as needed and can be difficult

Assessment steps

• Piaget learn more as focus so learn more a general
• Kholberg theory discuss what is good and bad but with the mind.
• As with others include biography, health
• And Validate needed

LESSON 8: ASSESSING GENERAL HEALTH STATUS AND VITAL SIGNS

• Structure and function, can know a persons health and what to
• General physical of their being
• general survey includes health, the skin, dress, consciousness
• sign and symptoms of vital
• cardio, neurology, peripherals and resipartoy
• temperature around 97 or 98

Evaluation Steps

• pulse use sight by seeing there beat per min,
• blood with height/low. By outside factors such cardio
• Older clients sign will have varies

Steps and Questions for Care

• validation add extra data that test the data and ok and good.
• To be sure data is there
• Questions 1: is tem high/low
• Question is there stonger pressure
• Validate has been ok

LESSON 9: ASSESSING PAIN

• Pain is unpleasent and emotional + that whaterver that patient is on there expercice is there + sign is the
• physcologic: trausduction, transmit, recpeciton
• some respond to pain as hoplenseless or anixitios
• others respond to pain with more. Heart rate + sweat more

Question For Patients in pain

• other classification: such when started to feel to. What happens over time or space
• some may believe in their spirit but
• some may be a culture
• tools is the to see number and make
• Questions 2: Should assess at moment
• Question 2: accept pain where is is to believe it

Steps to Follow

• Validate with signs
• In physical with see + find where it is

LESSON 10: ASSESSING FOR VIOLENCE

• Violence has control by someone to keep others
• includes physical, emotional, and sexual
• the act is to harm someone/dominate or master
• positive is to get ahest whih negative is to get what others do
• in 2008 theory look what happen what has cause such action .

The act of Abuse

• can happen in a minor to a major
• physical, emotional, and sex
• the act of being violent will affect everything
• physical, emotional, and action
• Domestic shelters and the actions

The Actions to know what is safe

• the action to help someone who is hurting includes
• war crimes, show immigrants how others see crime and safety
• Nursing Assessment of Family. Violence with no issue there
• Check with yourself and be active

Actions and Techniques

• Interview with action to build an ok state.
• Actions and tools to see danger and get a check

LESSON 11: ASSESSING CULTURE

• culture: behaviour, arts, beliefs that guide the decion
• with white, black other race that give
• culture that adapt
• learn when person adapt of their cultion.
• and see what culture they value with respect