Health Assessment Week 1 PDF

Health Assessment Week - 1 y Melinda L. Gonzales MAN RN  Overview of Nursing Process (ADPIE), Health Assessment in Nursing Practice, & Nurses Role in Health Assessment DEFINITION OF NURSING Nursing is both A SC...

Health Assessment Week - 1 y Melinda L. Gonzales MAN RN  Overview of Nursing Process (ADPIE), Health Assessment in Nursing Practice, & Nurses Role in Health Assessment DEFINITION OF NURSING Nursing is both A SCIENCE and an ART that is concerned Nursing is the diagnosis and with the individual’s: treatment of human 1.Physical responses to health 2.Psychological and illness – ANA 1995 3.Sociological 4.Cultural 5.Spiritual 4 ESSENTIALS FEATURES OF THE NURSING PRACTICE - ANA 1995 1. Full range of human experiences and responses to health and illness w/o restriction to a problem focused orientation (attention) 2. Caring relationship that facilitates health and healing 3. Understanding and integration of objective data based on the client’s subjective experience 4. Knowledge (scientific) for diagnosis and treatment  Health Assessment is: The first step of the Nursing Process. The most important because it directs the rest of the process A thinking, doing, and feeling process – think as you act and interact with patients think critically as you go with the process A skill learning the normal identify the normal and differentiate it from the abnormal The Nursing Process cont. - Is a systematic, organized method of planning, and providing quality and individualized nursing care. - It is synonymous with the Problem Solving Approach that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result 5 The Nursing Process cont. - The Nursing Process is a systematic Problem Solving Approach where diagnosis and treatment are achieved - It is a G O S H approach for efficient and effective provision of nursing care. - G - goal oriented - O - organized - S - systematic - H – humanistic 6 5 steps of the Nursing Process assessment diagnosis evaluation planning intervention 7  1. Assessment Identifies your patient’s strengths Sets the and tone for the Systematic The most limitations rest of the and is collection important process, and performed of data step the rest of not just the process once, but flows from it continuously throughout the nursing process 8 2. Diagnosis A. Clinical judgment concerning a human response to health conditions / life processes, or B. Analysis of data to vulnerability for that identify the problem response by an individual, family or community that the nurse is licensed and competent to treat C. Formulating a nursing diagnosis involves identifying and prioritizing actual or potential health problems or responses. a.An actual nursing diagnosis identifies an occurring health problem for your patient. b.A potential nursing diagnosis identifies a high-risk health problem that most likely will occur unless preventive measures are taken. c.A possible nursing diagnosis is one that needs further data to support it D. Types of Nursing Diagnosis 1. Problem – focused Nursing Diagnosis a. Problem + Etiology + Signs and Symptoms b. Example: “Acute pain related to trauma of surgical incision as evidenced by facial grimace and guarding behavior” “Ineffective Airway clearance related to seizure activity as manifested by increase oral secretion.” 2. Risk Nursing Diagnosis a. Problem + Etiology b. Example “Risk for infection related to surgical incision” “Risk for Bleeding related to trauma from abortion” 3. Health Promotion Nursing Diagnosis a. Problem: Grieving, Hopelessness b. Example: “Readiness for enhanced Knowledge: expresses an interest in learning” “Readiness for enhanced decision-making as evidenced by participation in healthcare decisions” 4. Syndrome Nursing Diagnosis Specific cluster of nursing diagnosis that occur together and have similar nursing interventions to resolve the situation Chronic pain syndrome as manifested by anxiety and disturbed sleep pattern. Defining Characteristics (Signs and Symptoms) Observable assessment cues such as patient behavior, physical signs Related Factor (Etiology) Etiological cause or causative factor for 3. Planning - Desired outcomes - Appropriate interventions - Involves setting goals and outcomes - Individualized plan of care for your patient is ready once diagnosis have been prioritized Planning con - Priority Setting - Ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions - Goals - Broad statement that describes a desired change in a patient’s condition, perceptions or behavior -Types of Goals a. Long Term Goals: - objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks or months b. Short Term Goals: - objective behavior or response that you expect the patient to achieve in short time usually few hours or less than a week Planning should be: specific SMART measurable attainable realistic Time-bound 4. Intervention -Defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. -Putting the plan of care into action -Also called Implementation -Involves carrying out your plan to achieve goals and outcomes -The “doing” phase -Approach in intervention a. Direct Care - Direct intervention - Interventions are treatment performed through interaction with patient - Ex. Giving medication, V/S checking, insertion of IFC b. Indirect Care - Interventions are treatments performed away from a patient but on behalf of the patient or group of patient - Ex. Safety and Infection control Types of Intervention: 1. Independent - Action that the nurse initiates without supervision or direction from others 2. Dependent - Actions that require an order from a health care provider or the attending physician. 3. Collaborative - Interdependent interventions - Therapies that require the combined knowledge, skills, and expertise of multiple health care providers 5. Evaluation -Final step of the nursing process -Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process -Monitoring of clients progress -Alter the plan as indicated -Involves determining the effectiveness of your plan. -Once again, assess your patient’s response based on the criteria you set for the outcome. ⊚ The Nurse assessment Must Take Note: evaluat diagnosi - The steps of the ion s nursing process are interrelated forming a continuous circle of thought and intervent plannin action that is both ion g dynamic and cyclic. 23  Characteristics of the Nursing Dynamic ProcessPatient and cyclic centered Goal directed Flexible Problem oriented Cognitive Action oriented Interpersonal Holistic 24 Purposes Of The Nursing Process 1. To identify a client’s health status; his Actual/Present and potential/possible health problems or needs. 2. To establish a plan of care to meet identified needs. 3. To provide nursing interventions to meet those needs. NURSING ASSESSMEN T DEFINITION OF ASSESSMENT Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and coping patterns.  A. Initial Nursing 4 Different Assessment B. Ongoing or Partial Types of Assessment Nursing C. Focused or Problem Assessment Oriented Assessment D. Emergency Assessment 1. INITIAL COMPREHENSIVE ASSESSMENT Known as “TRIAGE” The nurse typically collects both subjective data and objective data Also involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices. Time Performed: Performed within a specified time after admission to a healthcare agency Purposes: To establish a complete database for problem identification, reference, and future comparison Example: 2. ONGOING OR PARTIAL ASSESSMENT Consists of data collection that occurs after the comprehensive database is established. Consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes (deterioration or improvement) from the baseline data. This type of assessment is usually performed whenever the nurse or another health care professional has an encounter with the client. The frequency of this type of assessment is determined 3. FOCUSED OR PROBLEM-ORIENTED ASSESSMENT A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern. A focused assessment consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. Ex: Problem is Pain - ask questions the character, location of pain, onset, relieving and aggravating factors, and associated symptoms. 4. Emergency Assessment An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment. An example of an emergency assessment is the evaluation of the client’s airway, breathing, and circulation (known as the ABCs) when cardiac arrest is suspected. The major and only concern during this type of assessment is to determine the status of the client’s life sustaining physical functions. NURSE’S ROLE IN HEALTH ASSESSMENT The acute care nurse performs a focused assessment, and then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care.  Critical care outreach nurses need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment (Coombs & Moorse, 2002). Ambulatory care nurses assess and screen clients to determine the need for  Home health nurses make independent nursing diagnoses and referrals for collaborative problems as needed. Public health nurses assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT LATE 1800s–EARLY 1900s Nurses relied on their natural senses; the client’s face and body would be observed for “changes in color, temperature, muscle strength, use of limbs, body output, and degrees of nutrition, and Palpation hydration”was (Nightingale, used to measure pulse rate and quality 1992). and to locate the fundus of the puerperal woman (Fitzsimmons & Gallagher, 1978). 1930–1949 The American Journal of Public Health documents routine client and home inspection by public health nurses in the 1930s. This role of case finding, prevention of communicable diseases, and routine use of assessment skills in poor inner-city areas was performed through the Frontier Nursing Service and 1950–1969 Nurses were hired to conduct pre- employment health stories and physical examinations for major companies, such as New York Telephone, from 1953 through 1960 (Bews & Baillie, 1969; Cipolla & Collings, 1971). 1970–1989 The early 1970s prompted nurses to develop an active role in the provision of primary health services and expanded the professional nurse role in conducting health histories and physical and psychological assessments (Holzemer, Barkauskas, & Ohlson, 1980; Lysaught, 1970). Acute care nurses in the 1980s employed the “primary 1990–PRESENT In the 1990s, critical pathways or care maps guided the client’s progression, with each stage based on specific protocols that the nurse was responsible for assessing and validating. Advanced practice nurses have been increasingly used in the hospital as clinical nurse specialists and in the References: Weber, J.R., and Kelley, J. H., (2021) Health Assessment in Nursing 7th Edition, Philadelphia: Wolters Kluwer D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition, Singapore: Pearson Education, Inc. https://www.registerednursern.com/head-toe-assessment-nursing/ https://www.ahrq.gov/sites/default/files/publications/files/health-assessments_ 0.pdf Week – 1: Assessment Task (20 pts) PROBLEMS: a. Diarrhea d. Insomnia b. Allergy e. Abdominal pain c. Overweight 1. Choose 1 from above. Formulate a Nursing care Plan Generate Nursing Diagnosis using: a. Problem- Focused Nursing Diagnosis 2. Submission will be on Feb. 06, 2025. Name: Block: Assessment Nursing Planning Implementatio Evaluation Diagnosis n Subjective: Problem- Short Term Independent: Focused Nursing Goals: Diagnosis Objective: Dependent: Long Term Goals: Collaborative: Thank You