Chapter 1: The Nurse's Role in Health Assessment - Wolters Kluwer

Chapter 1 The Nurse’s Role in Health Assessment The Nursing Process Copyright © 2022 Wolters Kluwer · All Rights Reserved Phases of Nursing Process  Assessment: Collecting subjective and objective data  Diagnosis: Analyzing subjective and objective data to make a profess...

Chapter 1 The Nurse’s Role in Health Assessment The Nursing Process Copyright © 2022 Wolters Kluwer · All Rights Reserved Phases of Nursing Process  Assessment: Collecting subjective and objective data  Diagnosis: Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral)  Planning: Determining outcome criteria and developing a plan  Implementation: Carrying out the plan  Evaluation: Assessing whether outcome criteria have been met and revising the plan as necessary Copyright © 2022 Wolters Kluwer · All Rights Reserved Step 1: Assessment  First and most critical phase  Collecting subjective and objective data  May lead to inadequate or inaccurate, incorrect clinical judgments if completed incorrectly  Is ongoing and continuous throughout all phases  More than just gathering information Copyright © 2022 Wolters Kluwer · All Rights Reserved Focus of Health Assessment in Nursing  Physical medical assessment o Focuses primarily on the client’s physiologic development status  Holistic nursing assessment o Collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment o Mind, body, and spirit interdependent factors that affect each client’s level of health Copyright © 2022 Wolters Kluwer · All Rights Reserved Framework of Health Assessment in Nursing  Many valid nursing assessment framework methods available  Four basic sections o History of present health concern o Personal health history o Family history o Lifestyle and health practices Copyright © 2022 Wolters Kluwer · All Rights Reserved Using Evidence to Promote Health and Prevent Disease  “Evidence-Based Health Promotion and Disease Prevention”  Healthy People 2030  Many tools available to screen clients for potential health risks  USPSTF—risk versus benefit in screenings Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Physical medical assessment collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Holistic nursing assessment collects holistic subjective and objective data to determine a client’s overall level of functioning in order to make a professional clinical judgment. Physical medical assessment focuses primarily on the client’s physiologic development status. Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Health Assessments #1  Initial comprehensive assessment o Subjective data o Past health history o Family history o Lifestyle and health practices o Objective data o Frequency of comprehensive assessments depends on age, risk factors, health status, health promotion practices, lifestyle Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Health Assessments #2  Ongoing or partial assessment o Continued data collection after comprehensive assessment o Mini overview o Reassessed any problems o Detect any new problems Copyright © 2022 Wolters Kluwer · All Rights Reserved Types of Health Assessments #3  Focused or problem-oriented assessment o Does not replace comprehensive assessment o Thorough assessment of particular client problem o Does not address areas not related to problem  Emergency assessment  Very rapid assessment in life-threatening situations  Goal—provide prompt treatment  Only concern is preventing death Copyright © 2022 Wolters Kluwer · All Rights Reserved Steps of Health Assessment #1  Four major steps: o Collection of subjective data o Collection of objective data o Validation of data o Documentation of data  Steps tend to overlap  May preform 2 or 3 steps concurrently Copyright © 2022 Wolters Kluwer · All Rights Reserved Steps of Health Assessment #2  Preparing for the assessment o Review client’s record o Review client’s status with other health care team members o Educate about client’s diagnosis and tests performed o Reflect on your personal feelings regarding initial encounter with client o Obtain and organize materials needed for assessment Copyright © 2022 Wolters Kluwer · All Rights Reserved Collecting Subjective Data  Biographical information  History of present health concern; physical symptoms related to each body part or system  Personal health history  Family history  Health and lifestyle practices  Review of systems Copyright © 2022 Wolters Kluwer · All Rights Reserved Collecting Objective Data  Physical characteristics  Body functions  Appearance  Behavior  Measurements  Results of laboratory testing Copyright © 2022 Wolters Kluwer · All Rights Reserved Validating Assessment Data  Crucial part of assessment  Ensures assessment process is not ended before all relevant data have been collected  Helps prevent documentation of inaccurate data Copyright © 2022 Wolters Kluwer · All Rights Reserved Documenting Data  Forms the database for entire nursing process  Provides data for all other members of health care team  Ensures valid conclusions are made Copyright © 2022 Wolters Kluwer · All Rights Reserved Step 2: Analyzing Cues to Identify Client Concerns  Identify abnormal cues and supportive cues  Cluster cues  Draw inferences and identify and prioritize client concerns  Propose possible collaborative problems to notify primary care provider  Identify need for referral to primary care provider  Document conclusions Copyright © 2022 Wolters Kluwer · All Rights Reserved Factors Affecting Health Assessment  Culture, family, community will affect each client, even if only in subtle ways  Must be aware of any perceived notions of yourself Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 What occurs during the assessment phase of the nursing process? A. Collect subjective and objective data. B. Determine outcome criteria and develop a plan of care. C. Carry out the plan. D. Assess whether outcome criteria have been met and revise the plan as necessary. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 A. Collect subjective and objective data. Assessment is collection of subjective and objective data. Planning is determining outcome criteria and developing a plan. Implementation is carrying out the plan. Evaluation is assessing whether outcome criteria have been met and revising the plan as necessary. Copyright © 2022 Wolters Kluwer · All Rights Reserved