Ch1, Intro, student-1.pptx

Chapter 1 INTRODUCTION TO HEALTH ASSESSMENT CATHY BINSTOCK, UNMC CON Why Learn Health Assessment? Health assessment is a systematic method of collecting and analyzing data. Used to create a patient-centered plan-of-care. Utilize the American Nurses Association’s (ANA) Standards of Pract...

Chapter 1 INTRODUCTION TO HEALTH ASSESSMENT CATHY BINSTOCK, UNMC CON Why Learn Health Assessment? Health assessment is a systematic method of collecting and analyzing data. Used to create a patient-centered plan-of-care. Utilize the American Nurses Association’s (ANA) Standards of Practice, which incorporates the nursing process. What additional benefits?  Three primary components: ◦ History (subjective data) ◦ Physical examination (objective data) Compone ◦ Documentation of data nts of Health Data collection ◦ Symptom: What the patient Assessme feels/communicates (subjective) nt ◦ Sign: Clinical findings (objective) collected during physical examination ◦ Clinical manifestations = signs and/or symptoms collected utilizing inspection, palpation, percussion, and auscultation Documentation of Data Improves plan of care Legal document of patient’s health status Baseline for ◦ Evaluation ◦ Changes and decisions related to care Must be accurate, concise, and without bias or opinion Must be done at the time of care Standards of Nursing Practice 1. Assessment 2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation Nursing Process The nursing process is used to ◦ Identify patient's health status, actual or potential healthcare problems, needs ◦ Establish plans to meet needs ◦ Deliver specific nursing interventions ◦ Evaluate success of interventions Patient may be individual, family, or group Nursing process is dynamic, not static Nursing process is patient-centered Nursing process is adaptation of problem solving used by those in patient care ◦ Directed toward patient’s response to disease process, effects of disease process, interventions, therapies Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved PEARSON, COPYRIGHT 2023, 2019,2015 PEARSON EDUCATION INC., ALL RIGHTS RESERVED Nursing Process Phases ◦ Assessment ◦ Diagnosis ◦ Planning ◦ Implementation ◦ Evaluation Decision making involved in every phase Phases not separate entities but interrelated, overlap Nursing process is interpersonal and collaborative Process always begins with accurate data collection Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved  Nursing Process: Assessment  Assessment: actual and potential problems based on data collection  Subjective data  Objective data  Sources of data: medical records, data bases  Organize data, concept based model  Analyzing assessment data  Clustering data  Identify gaps Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved Nursing Process: Diagnosis Critical thinking skills to cluster and identify problems Formulate Nursing diagnosis ◦Nursing diagnosis is judgment made only after thorough assessment ◦Nursing diagnoses describe continuum of health states Types of nursing diagnoses ◦Problem-focused diagnosis ◦Risk nursing diagnosis ◦Health promotion diagnosis ◦Syndrome diagnosis ◦ Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved  Nursing Diagnosis: Planning Goals: Smart goals ◦Follow acronym SMART ◦Single specific action ◦Short term and ◦Measurable long term ◦Attainable ◦Relevant ◦Patient centered ◦Time limited ◦Goal statement in form of ◦Measurable ◦Subject: the patient ◦Verb: the specific action patient is to ◦Attainable perform ◦Goal: patient and nurse’s intended ◦Timed achievement ◦Time limit: when goal should be ◦Evaluates accomplished progress ◦Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved Nursing Process: Implementation Nursing Interventions Independent, Dependent and collaborative care Direct and indirect care Focus on ◦ Assessing to observe for change in patient’s status ◦ Reassess ◦ Preventing complications ◦ Reducing risk factors ◦ Treating through teaching and providing physical care ◦ Improving health through health promotion, achieving higher levels of wellness ◦ Patient focused ◦ Rationale ◦ Priority Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved Nursing Process: Evaluation Evaluation is the planned, continuous, intentional reassessment of cues to ◦ Determine patient’s progress toward achieving goals ◦ Evaluate the effectiveness of the action taken Feedback and participation of patient and support are key indicators of the quality and effectiveness of interventions Evaluation continues until goals achieved or has reached an optimal state Evaluation is a planned and deliberate activity that occurs during, immediately after, or at time intervals after an intervention takes place Evaluation at discharge includes status of goal achievement, self- care abilities with regard to follow-up Conclusions, revisions and documentation Pearson Copyright 2023,2019,2015 Pearson Education, Inc. All Rights Reserved Types of Health Assessment Amount of information gained during a health assessment depends on several factors, including: ◦ Context of care ◦ circumstance or situation related to health care delivery. ◦ May be related to the physical, psychologic, or socioeconomic circumstances involving the patient. ◦ May be related to the setting or environment ◦ Patient need ◦ Expertise of the nurse Examples: Types of Assessments Comprehensive health assessment Problem-based or focused health assessment Episodic assessment Screening assessment Assessment Patient needs vary widely: ◦ Type of health assessment performed by the nurse is driven by the patient’s need. ◦ Nurse must be prepared to conduct appropriate level of assessment. ◦ Patient’s age, general level of health, presenting problems, knowledge level, and support systems are among the variables that impact patient need. Experience of the nurse: ◦ A nurse in the intensive care unit takes care of patients who have monitors and are possibly unstable ◦ A practitioner in a clinic may need to have skill at using an otoscope. Clinical Reasoning and Judgment Analyze and interpret data before initiating a plan of care. The outcome of health assessment is a portrait of the patient’s physical status, strengths, weaknesses, abilities, support system, health beliefs, and activities to maintain health, as well as the patient’s health problems and available resources to maintain health. Evidence Based Practice (EBP): Supports or disputes the efficacy of treatment, the use of a tool, how a disease is transmitted is just a few examples in health care. EBP is fundamental to health care and nursing care. (Giddens)  Learning to recognize patterns Applying concepts to nursing practice Developin g Clinical Skillful responding Judgment Reflective practice Measuring and evaluating clinical judgment Data Organization Organization and clustering of data ◦ Allows problems to be more clearly apparent Can be based on body system format: ◦ Cardiovascular, musculoskeletal, etc. Can be based on conceptual format: ◦ Oxygenation, perfusion, mobility Analysis, Interpretation, and Clinical Judgment Data analysis, interpretation, and clinical judgment include: ◦ Identifying abnormal findings. ◦ Correctly interpreting findings to select appropriate plan of care. ◦ Applying clinical judgment to interpret or make conclusions regarding patient needs, concerns, or health problems. ◦ After understanding the situation, the nurse responds by determining appropriate interventions. Health Promotion and Health Protection health assessment—data to identify patient’s health status, practices, and risk factors. Interpretation of data allows the nurse to target health promotion needs. Health promotion: ◦ Behavior motivated by desire to increase well-being and actualize health potential. Health protection: ◦ Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill. Three Levels of Health Promotion Three levels of health promotion: ◦ Primary = Preventing disease from developing through promoting healthy lifestyle. ◦ Secondary = Screening efforts to promote early detection of disease. ◦ Tertiary = Minimizing disability from acute or chronic illness or injury and allowing for most productive life within limitations. Nurses provide education and care to help meet health promotion needs. Framework for health promotion efforts found in Healthy People 2030: https://health.gov/healthypeople Question 1 A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that: A. The patient receives a refill for her thyroid medication. B. The patient is instructed on preventive measures for hypertension. C. Other family members are present during the interview. D. Information about the patient’s lifestyle habits is gathered. Question 2 A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of: A. Health education B. Primary prevention C. Secondary prevention D. Tertiary prevention