Week 1 Health Assessment PDF

BACHELOR OF SCIENCE IN NURSING: HEALTH ASSESSMENT COURSE MODULE COURSE UNIT WEEK 1 1 1 Overview of Nursing Process (ADPIE), Health Assessment in Nursing Practice, & Nur...

BACHELOR OF SCIENCE IN NURSING: HEALTH ASSESSMENT COURSE MODULE COURSE UNIT WEEK 1 1 1 Overview of Nursing Process (ADPIE), Health Assessment in Nursing Practice, & Nurses Role in Health Assessment ✓ Read course and unit objectives ✓ Read study guide prior to class attendance ✓ Read and comprehend required learning resources ✓ Engage in classroom discussions ✓ Participate in weekly discussion board (Canvas) ✓ Answer and submit course unit tasks At the end of this unit, the students are expected to: Cognitive: 1. Discuss how nursing assessment skills are needed for every situation the nurse encounters 2. Differentiate between a holistic nursing assessment and a physical medical assessment 3. Describe which phases of the nursing process involve assessment by the nurse 4. List and describe the steps of the nursing process, explaining how some steps overlap and may have to be repeated many times when caring for a client. 5. Describe the steps of the “analysis phase” of the nursing process. 6. Explain how the nurse’s role in assessment has changed over the past century. Affective: 1. Inculcate importance of the nursing process in the nursing profession. 2. Listen attentively during class discussions. 3. Demonstrate tact and respect when challenging other people’s opinions and ideas. 4. Accept comments and reactions of classmates on one’s opinions openly and graciously. Psychomotor: 1. Participate actively during class discussions 2. Confidently express personal opinion and thoughts in front of the class Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia: Wolters Kluwer A. OVERVIEW OF THE NURSING PROCESS (ADPIE) HEALTH ASSESSMENT “The very elements of nursing are all but unknown” - FLORENCE NIGHTINGALE 1859 DEFINITION OF NURSING Nursing is the diagnosis and treatment of human responses to health and illness – ANA 1995 WHAT IS NURSING? Nursing is both A SCIENCE and AN ART that is concerned with the individual’s: 1. Physical 2. Psychological 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 Will USE in every area of nursing How well you perform your assessment will affect everything else that follows. You will ask questions, and you will use four of your senses to collect data. FUNDAMENTAL PHILOSOPHICAL BELIEFS IN NURSING 1. The client is a human being who has worth and has dignity. 2. Humans manifest an essential unity of mind/body and spirit. 3. There are basic human needs that must be met. 4. When these needs are not met, problems arise that may require intervention by another person until the individual can resume responsibility for themselves. 5. Human experience is contextually and culturally defined. 6. Clients have a right to quality health and nursing care delivered with interest, compassion and competence, with a focus on wellness and prevention. 7. The therapeutic nurse-client relationship is important in the nursing process. WHAT IS THE NURSING PROCESS? “Combines the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method” – Shore 1988 “This process incorporates an interactive/interpersonal approach with a problem solving and decision- making process” – Peplau 1952 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 IN SHORT – 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 - oal oriented ✓ O - rganized ✓ S - ystematic ✓ H - umanistic care 5 steps of the Nursing Process (ADPIE) 1. ASSESSMENT 2. DIAGNOSIS 3. PLANNING 4. INTERVENTION 5. EVALUATION ASSESSMENT Systematic collection of data The most important step Sets the tone for the rest of the process, and the rest of the process flows from it Identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process DIAGNOSIS Clinical judgment concerning a human response to health conditions / life processes, or vulnerability for that response by an individual, family or community that the nurse is licensed and competent to treat Analysis of data to identify the problem Formulating a nursing diagnosis involves identifying and prioritizing actual or potential health problems or responses. ✓ An actual nursing diagnosis identifies an occurring health problem for your patient. ✓ A potential nursing diagnosis identifies a high-risk health problem that most likely will occur unless preventive measures are taken. ✓ A possible nursing diagnosis is one that needs further data to support it Types of Nursing Diagnosis 1. Problem – focused ND Problem + Etiology + Signs and Symptoms Acute pain related to trauma of surgical incision as evidenced by facial grimace and guarding behavior 2. Risk ND Problem + Etiology Risk for infection related to surgical incision 3. Health Promotion ND Problem Grieving, Hopelessness 4. Syndrome ND Specific cluster of nursing diagnosis that occur together and have similar nursing interventions to resolve the siyuation Defining Characteristics (Signs and Symptoms) ✓ Observable assessment cues such as patient behavior, physical signs Related Factor (Etiology) ✓ Etiological cause or causative factor for diagnosis PLANNING Desired outcomes Appropriate interventions Involves setting goals and outcomes Individualized plan of care for your patient is ready once diagnosis have been prioritized 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 ▪ 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 ▪ 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 ✓ Measurable ✓ Attainable ✓ Realistic ✓ Time-bound 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 ✓ Direct Care ▪ Direct intervention ▪ Interventions are treatment performed through interaction with patient ▪ Ex. Medication administration, VS checking, insertion of IFC ✓ 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, Delegating nursing care Types ✓ Independent  ▪ Action that the nurse initiates without supervision or direction from others ✓ Dependent ▪ Actions that require an order from a health care provider ✓ Collaborative ▪ Interdependent interventions ▪ Therapies that require the combined knowledge, skills, and expertise of multiple health care providers 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 client’s 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 Must Take Note: The steps of the nursing process are interrelated forming a continuous circle of thought and action that is both dynamic and cyclic. The nurse must be able to apply some basic abilities on the knowledge of science and theory. Creativity and adaptability are very important 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 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. 4. To provide an individualized, holistic, effective and efficient nursing care. B. TYPES OF HEALTH ASSESSMENT DEFINITION OF ASSESSMENT According to Carpenito: 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. According to Atkinson and Murray (1991): Assessment is a part of each activity the nurse does for and with the patient. The four basic types of assessment are: 1. Initial comprehensive assessment 2. Ongoing or partial assessment 3. Focused or problem-oriented assessment 4. Emergency assessment Initial Comprehensive Assessment 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 (which includes information related to the client’s overall function) as well as objective data gathered during a step-by-step physical examination. The nurse typically collects subjective data and objective data in many settings (hospital, community, clinic, or home). Depending on the setting, other members of the health care team may also participate in various parts of the data collection. Eg. o In a hospital setting the physician usually performs a total physical examination when the client is admitted (if this was not previously done in the physician’s office). In this setting, the nurse continues to assess the client as needed to monitor progress and client outcomes. A physical therapist may perform a musculoskeletal examination, as in the case of a stroke patient, and a dietitian may take anthropometric measurements in addition to a subjective nutritional assessment. o In a community clinic, a nurse practitioner may perform the entire physical examination.  o In the home setting, the nurse is usually responsible for performing most of the physical examination. Regardless of who collects the data, a total health assessment (subjective and objective data regarding functional health and body systems) is needed when the client first enters a health care system and periodically thereafter to establish baseline data against which future health status changes can be measured and compared. o Frequency of comprehensive assessments depends on the client’s age, risk factors, health status, health promotion practices, and lifestyle. Ongoing or Partial Assessment Consists of data collection that occurs after the comprehensive database is established. This 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. In addition, a brief reassessment of the client’s body systems and holistic health patterns is performed to detect any new problems. This type of assessment is usually performed whenever the nurse or another health care professional has an encounter with the client. This type of assessment may be performed in the hospital, community, or home setting. The frequency of this type of assessment is determined by the acuity of the client. Eg. o A client admitted to the hospital with lung cancer requires frequent assessment of lung sounds. A total assessment of skin would be performed less frequently, with the nurse focusing on the color and temperature of the extremities to determine level of oxygenation. 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. Eg. o If your client, John P., tells you that he has pain you would ask him questions about the character and location of pain, onset, relieving and aggravating factors, and associated symptoms. However, asking questions about his sexual functioning or his normal bowel habits would be unnecessary and inappropriate. The physical examination should focus on his ears, nose, mouth, and throat. At this time, it would not be appropriate to perform a comprehensive assessment by repeating all system examinations such as the heart and neck vessel or abdominal assessment. 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.  C. NURSE’S ROLE IN HEALTH ASSESSMENT In the 21st century, the nurse’s role in assessment continues to expand, becoming more crucial than ever. The role of the nurse in assessment and diagnosis is more prevalent today than ever before in the history of nursing. The rapidly evolving roles of nursing (e.g., forensic nursing) require extensive focused assessments and the development of related nursing diagnoses. o The acute care nurse performs a focused assessment, and then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care. o 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). o Ambulatory care nurses assess and screen clients to determine the need for physician referrals. o Home health nurses make independent nursing diagnoses and referrals for collaborative problems as needed. o Public health nurses assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families. There is tremendous growth of the nursing role in the managed care environment. The most marketable nurses will continue to be those with strong assessment and client teaching abilities as well as those who are technologically savvy. The following are factors that will continue to promote opportunities for nurses with advanced assessment skills: o Rising educational costs and focus on primary care that affect the numbers and availability of medical students o Increasing complexity of acute care o Growing aging population with complex comorbidities o Expanding health care needs of single parents o Increasing impact of children and the homeless on communities o Intensifying mental health issues o Expanding health service networks o Increasing reimbursement for health promotion and preventive care services 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 hydration” (Nightingale, 1992). Palpation was used to measure pulse rate and quality and to locate the fundus of the puerperal woman (Fitzsimmons & Gallagher, 1978).  Examples of independent nursing practice using inspection, palpation, and auscultation have been recorded in nursing journals since 1901. 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 the Red Cross (Fitzsimmons & Gallagher, 1978). 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 care” method of delivery of care. Each nurse was autonomous in making comprehensive initial assessments from which individualized plans of care were established. 1990–PRESENT Over the last 20 years, the movement of health care from the acute care setting to the community and the proliferation of baccalaureate and graduate education solidified the nurses’ role in holistic assessment. 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 community as nurse practitioners. PHYSICAL refers to the body, this marvelous container and complex, finely tuned, machine with which we interface with our environment and fellow beings. The physical self is the concrete dimension, the tangible aspect of the person that can be directly observed and examined. PSYCHOLOGICAL pertaining to the mind or to mental phenomena as the subject matter of psychology. of, pertaining to, dealing with, or affecting the mind, especially as a function of awareness, feeling, or motivation: psychological play; psychological effect. SOCIOLOGICAL of or relating to sociology or to the methodological approach of sociology. Oriented or directed toward social needs and problems. CULTURAL the characteristics and knowledge of a particular group of people, encompassing language, religion, cuisine, social habits, music and arts SPIRITUAL relating to religion or religious belief. Relating to or affecting the human spirit or soul as opposed to material or physical things. 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 Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia: Wolters Kluwer https://www.all-about-psychology.com/the-concept-of-physical-self- in- psychology.html#:~:text=Physical%20Self%20refers%20to%20the, be%20directly%20observed%20and%20examined. https://www.dictionary.com/browse/psychological https://www.merriam-webster.com/dictionary/sociological https://www.livescience.com/21478-what-is-culture-definition-of-culture.html https://www.lexico.com/en/definition/spiritual