Nursing: Health Assessment and the Nursing Process

• Nursing is defined as protecting, promoting, and optimizing health and abilities.
• It includes preventing illness and injury and alleviating suffering through diagnosis, treatment of human responses, and advocacy.
• Nursing emphasizes diagnosing and treating human responses based on accurate client assessments.
• Effective nursing interventions promote health and prevent illness or injury.

Health Assessment Defined

• The first step of the nursing process.
• Directs the rest of the nursing process.
• It involves thinking, doing, and feeling, requiring nurses to think critically.
• Health assessment a skill used in every nursing area, is about learning what is normal
• It allows nurses to identify and differentiate between normal and abnormal findings.

The Nursing Process

• Combines the art of nursing with systems theory and the scientific method.
• Incorporates an interactive and interpersonal approach.
• It uses problem-solving and decision-making.
• A systematic and organized method for planning and providing quality, individualized care.
• It directs nurses and clients to determine the need for care, plan and implement it, and evaluate the results.
• The nursing process is a systematic problem-solving approach where diagnosis and treatment are achieved.
• It is a "GOSH" approach - Goal oriented, Organized, Systematic, and Humanistic.

Characteristics of the Nursing Process

• Dynamic and cyclic
• Patient-centered
• Goal directed
• Flexible
• Problem-oriented
• Cognitive
• Action-oriented
• Interpersonal
• Holistic
• Systematic

Purposes of the Nursing Process

• Identify a client's health status, including actual, present, potential, and possible health problems or needs.
• Establish a plan of care to meet identified needs.
• Provide nursing interventions to meet those needs.
• Provide individualized, holistic, effective, and efficient nursing care.

Assessment Defined

• Involves the systematic and continuous collection, organization, validation, and documentation of data.
• According to Carpenito, assessment is the deliberate, systematic collection of data to determine a client's current and past health.
• It looks at functional status and coping patterns.
• According to Atkinson and Murray (1991), assessment is part of each activity a nurse does for and with the patient.

Types of Health Assessment

• Initial Comprehensive Assessment: involves subjective and objective data collection on the client’s health, past history, lifestyle, and practices via physical examination.
• Ongoing or Partial Assessment: consists of a mini-overview follow-up on health status.
• Problems initially detected in the client’s body or holistic health patterns are reassessed to determine changes.
• Focused or Problem-Oriented Assessment: It performed when a comprehensive database exists for a client with a specific health concern, involving a thorough assessment of a particular client problem.
• Emergency Assessment: a rapid assessment performed in life-threatening situations to provide prompt treatment; for example – checking a patient's ABCs

Steps of Health Assessment

• Collection of subjective data
• Collection of objective data
• Validation of data
• Documentation of data
• Data collection is the process of gathering information about a client's health status.

Collecting Subjective Data

• Subjective data includes sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences, beliefs, ideas, values, and personal information
• Elicit accurate subjective data by using effective interviewing skills.
• Elements include biographical information (name, age, religion, occupation)

History of Present Health Concern

• Involves physical symptoms related to body parts or systems (e.g., eyes, ears, or abdomen), personal and family health history.
• Looks at health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure/function, and community environment)

Collecting Objective Data

• Data gathered through direct observation by the examiner.
• Includes physical characteristics (e.g., skin color, posture), body functions (e.g., heart rate, respiratory rate), appearance (e.g., dress and hygiene), and behavior (e.g., mood, affect).
• Measurements are recorded as blood pressure, temperature, height, and weight in addition to the lab results.
• Objective data is obtained by the four physical examination techniques: inspection, palpation, percussion, and auscultation.

Validating Assessment Data

• Ensures the assessment process in not ended before all relevant data has been collected.
• Helps to prevent documentation of inaccurate data.
• Involves determining what types of assessment data should be validated, the different ways to validate data, and identifying areas where data are missing parts of the process.

Documenting Data

• Documentation forms the database for the nursing process and provides data for all health team members.
• Thorough and accurate documentation is vital to ensure valid conclusions when the data are analyzed.

Process of Data Analysis

• Diagnostic reasoning skills are required
• This process used to arrive at nursing diagnoses, collaborative problems, or need for referral.
• It involves seven major steps: identifying abnormal data and strengths, clustering the data, drawing inferences and identifying problems, and proposing possible nursing diagnoses.
• Check for defining characteristics of those diagnoses, confirming or ruling out nursing diagnoses, and documenting conclusions.

Nursing Diagnosis

• A clinical judgment concerning a human response to health conditions or life processes.
• The nurse must be licensed and competent to treat
• Data analysis used to identify the problem.
• Identification and prioritizing of actual or potential health problems or responses is used in the formulation.
• An actual nursing diagnosis identifies a current occurring health problem.
• A potential nursing identifies a high-risk health at risk of occuring unless preventative measures are taken.

Types of Nursing Diagnosis

• Problem-focused includes the problem, etiology, signs, and symptoms.
• Risk includes the problem and etiology.
• Health promotion ND contains the problem.
• Syndrome ND involves a specific cluster of nursing diagnoses that occur together and have similar nursing interventions to resolve the situation.
• Diagnoses characterized by observable assessment cues (patient behavior, physical sign) and related factor (etiology)

Planning

• Establishing desired outcomes and appropriate interventions.
• It also involves setting goals and outcomes.
• An individualized plan of care is ready once the diagnosis has been prioritized.
• Nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.
• Establishing Goals are broad statements which describe a desired change in a patient’s behavior
• Long term goals are objective behaviors or response to achieve weeks or months out
• Short term goals are objective behaviours or responses achieved in short time

Intervention or Implementation

• Any treatment based on clinical judgment and knowledge to enhance patient outcomes.
• Implementation is putting the plan of care into action to achieve goals and outcomes.
• The doing phase
• Direct care involves direct intervention and treatment performed with patients (e.g., medication administration, VS checking, insertion of IFC).
• Indirect care involves treatments performed away from a patient but on behalf of the patient or group of patients (e.g., safety and infection control or delegating nursing care).

Types of Intervention

• Independent - This is an action that the nurse initiates without supervision or direction from others
• Dependent - Actions that require an order from a health care provider
• Collaborative - including Interdependent interventions and therapies that require the combined knowledge, skills, and expertise of multiple health care providers

Evaluation

• Is the final step of the nursing process
• Determines if the patient's condition improved or worsened after application of the first four steps of the nursing process.
• It includes monitoring the client's progress, altering the plan as indicated, and determining the effectiveness of your plan
• Nurses must apply knowledge of science and theory.
• Creativity and adaptability are essential.

Nurse's Role in Health Assessment

• Expanding in the 21st century.
• The nurse's role in assessment and diagnosis is more prevalent today than ever.
• Acute care nurses performs focused assessments, and incorporates assessment findings with teams to develop plans of care.
• Rapidly evolving roles of nursing (e.g., forensic nursing)

Managed Care Environment

• Marketable nurses have strong assessment and client teaching abilities, and those who are technologically savvy.
• Rising educational costs
• Focus on primary care that affect the numbers and availability of medical students, and increasing complexity of acute care
• Growing aging population with complex comorbidities
• Expanding health care needs of single parents
• Intensifying mental health issues
• Expanding health service networks
• Increasing reimbursement for health promotion and preventive care services.