Health Assessment NRCM0 101 PDF

HEALTH ASSESSMENT NRCM0 101 Nurse’s Role in Health Assessment  The role of nurses in assessment is expanding as their roles in health care and in their practice expand.  A complete nursing health assessment requires a health professional to examine a...

HEALTH ASSESSMENT NRCM0 101 Nurse’s Role in Health Assessment  The role of nurses in assessment is expanding as their roles in health care and in their practice expand.  A complete nursing health assessment requires a health professional to examine a patient in a systematic fashion, from head to toe.  Nurses rely on self-reported symptoms, visual observation, reported health histories, and a physical medical examination to make a health assessment.  Nurses are with the patient 24 hours a day, and the Nurses’ Notes serve like a log of patient status for the whole duration of a patient’s stay. NURSING PROCESS  DEFINITION - A systematic, rational method of planning and providing nursing care.  GOAL - To identify a client’s healthcare status, actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs. There Fives Phases Of The Nursing Process A-D-P-I-E  Assessment,  Diagnosis,  Planning,  Implementation, And  Evaluation  Each phase of the process affects the other and are closely related. Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate, incorrect nursing judgements may be made and adversely affect the patient. PHASES  Assessment - (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history)  Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient)   Planning- Goal & Outcome formulated, Personalized to individual’s needs.  Implementation (perform the task or intervention)  Evaluation (was the intervention successful or unsuccessful) ASSESSMENT  A systematic, dynamic process by which the nurse through interaction with client, significant others and health care provider, collects and analyze data about the client.  American Nurses Association  The collection of data about an individual’s health state.  First and most critical phase of the nursing process. HEALTH ASSESSMENT DEFINITION:  An organized systematic assessment of human body appraisal of all factors relevant to client’s health.  includes collecting subjective data through interviewing the client and obtaining objective data by physically examining the client.  which involves the use of one’s senses to determine the general physical and mental conditions of the body by collecting both subjective and objective data.  Indications:  On admission  Health camps/ confinement  On discharge  Before and after diagnostic procedure  On follow up PURPOSE:  Establish a database for the client’s normal abilities, risk factors, and any current alterations in functions.  To get a clear picture of a client's health status and health related problems.  To identify cause and extend of disease.  To identify the problem at early stage.   To determine the nature of treatment required for the patient.  To contribute in medical research.  To identify client's strength, weakness, knowledge. attitude, motivation, support systems and coping skills.  To build rapport with patient and family.  To identify need for health teaching.  To compare clients’ health status with an ideal status. Principles of Health Assessment  An accurate and timely health assessment provides foundation for nursing care & intervention.  Go for comprehensive assessment.  The health assessment process should include data collection, documentation and evaluation of the client's health status.  All documents should be objective, accurate, clear, concise, specific and current.  It should be practiced in all settings whenever there is nurse-client interaction.  Information gathered should be communicated to other health care professional.  Keep the confidentiality TYPES OF ASSESSMENT 1. Initial Comprehensive Assessment 2. Ongoing or partial assessment 3. Focused or problem-oriented assessment 4. Emergency assessment 5. Time-lapsed assessment 1. Initial Comprehensive Assessment- - Assessment performed within a specified time on admission. - Initial identification of normal function, functional status and collection of data concerning actual or potential dysfunction. - Involves collection of subjective data about the:  o Client’s perception of his/her health of all body parts or systems, o Past health history o Family history, and lifestyle and health practices ( which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination.  When performed?  On the initial contact with the client.  WHERE:  Hospital, Community, clinic or home setting.  PURPOSE:  To have baseline for reference and future comparison.  EXAMPLE:  Nursing admission assessment. 2. ONGOING OR PARTIAL ASSESSMENT  Consist of data collection that occurs after the comprehensive database is established.  Consists of mini-overview of the client’s body systems and holistic health patterns as follow-up on his health status  When performed?  usually performed whenever the nurse or another health care professional has an encounter with the client Purposes:  Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data. Brief reassessment of the client's normal body /system or wholistic health patterns is performed to detect new problems. 3. Focused or problem-oriented assessment  consists of a thorough assessment of a particular health problem and does not cover areas not related to the problem Purpose: to have a thorough assessment on the special health concern of the client identified in an earlier assessment. When performed?  performed when a comprehensive database exists for a client’s and he/she comes to the health care agency with a special health concern. 4. Emergency assessment Aim:  a very rapid assessment performed in a life-threatening situations physiologic/physiologic crisis.  Time Frame: At anytime  E.g. – ABC assessment in Cardiac Arrest  - Assessment of suicidal attempt on violence Purpose: to determine the status of the client's life-sustaining physical functions ABC’s in the ER. ABCDE Assessment Airway Breathing, Circulation, Disability, Exposure - It focusing on the most life-threatening clinical problems. - stands for the prioritization of problems that heath care workers must assess first, and must address first. in emergency cases, nurses should start assessing for problems in Airway, then Breathing, then Circulation and so on. The same goes for addressing problems assessed. Priority is given to problems in airway, then breathing, then circulation and so on. The goals of ABCDE:  To provide life-saving treatment  To break down complex clinical situations into more manageable parts  To serve as an assessment and treatment algorithm  To establish common situational awareness among all treatment providers  To buy time to establish a final diagnosis and treatment Basics of the ABCDE approach  As a guide, here are the questions you should ask when doing the ABCDE assessment.  A – Is the airway patent?  B – Is the breathing sufficient?  C – Is the circulation sufficient?  D - What is the level of consciousness?  E – Are there any clues to explain the patient’s condition? The ABCDE approach with important assessment points and example of treatment options.  5. Time-lapsed assessment AIM:  comparison of client's current status to baseline data previously obtained.  E.g. - reassessment of client's functional health pattern done several months after initial assessment.  Time frame: Several Months ( 3,6,8 months or more) between assessment. ASSESSMENT SKILLS  1. OBSERVATION  2. INTERVIEW  3. Physical Examination Technique   4. INTUITION 1- OBSERVATION  comprises more than the nurse's ability to see the client,  nurses also use the senses of smell, hearing, touch, and rarely, the sense of taste.  includes looking, watching, examining.  begins the moment the nurse meets the client,  It is a conscious, deliberate skill that is developed through efforts and with an organized approach.  2 Aspects:  a. noticing the data.  b. selecting, organizing and interpreting the data. 2. INTERVIEW  a planned communication or a conversation with a purpose, E.g to get or give information, identify problems of mutual concern, evaluate change, teach, provide support. 3. Physical Examination Technique A systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems.3- 4. INTUITION -use of insight, instinct, and clinical experience to make clinical judgements about the client. Intuition plays a role in the nurse's ability to analyze cues rapidly, make clinical decisions, and implement nursing actions even though assessment data may be incomplete or ambiguous. it is a process based on knowledge and care experience and has a place beside research-based evidence. Nurses integrate both analysis and synthesis of intuition alongside objective data when making decisions. ASSESSMENT PROCESS – Report Data 1. Collecting Data 2. Organizing Data 3. Validating Data 4. Validating Data ASSESSMENT ACTIVITIES 1. Collect Data: process of compiling information about the client, begins with the first client contact. 2. Organize Data: clusters the information together in order to identify areas of strength and weaknesses. 3. Validate Data: referred to as double checking the information at hand, is the process of confirming the accuracy of assessment data collected. Validation assists in verifying and clarifying cues and inference. 4. Documenting Data: accurate documentation is essential which include all data collected about client's Sources of Data 1. Primary source: Patient/ Client - data directly gathered from the client using interview and physical examination. 2. Secondary source: - data gathered from client's family members, significant others, client's medical -records/chart, other members of health team, and related care literature/journals. TYPES OF DATA SUBJECTIVE DATA also known as symptoms or covert cues include the client's feeling and statement about his or her health problems and are best recorded as direct quotations from the client, such as * Every time I move, I feel nauseated." Information perceived only by the affected person. OBJECTIVE DATA also known as signs or overt cues, are observable and measurable (quantitative) that are obtained through observation, standard assessment techniques performed during the PE, laboratory and diagnostic testing. Lets Review! SUBJECTIVE or OBJECTIVE 1. Headache = SUBJECTIVE 2. Temp. 37.9 = OBJECTIVE 3. RR: 20 br/ min = OBJECTIVE 4. Toothache = SUBJECTIVE 5. Client states, * I haven't moved my bowel since Friday (3 days) = SUBJECTIVE 6. Cyanosis = OBJECTIVE 7. Urine output: 60 ml = OBJECTIVE 8. Ate only half of the food served = OBJECTIVE While Collecting data..... When you communicate to collect data Aware of verbal /nonverbal messages to patient Genuineness: be open honest and sincere with patient Respect: be Non judgemental, let him feel accepted as a unique individual Empathy: Is knowing what patient means and acknowledge and understand how he/she feels Do you asked enough questions or Do you settle for what you know? PREPARED BY : EVANGELINE F. SOMBILUNA RN,MAN