Ncm 101 Health Assessment (Week 1)

Nursing​- A unique blend of art And science Applied within the context of Interpersonal
relationship. Erase unique because nurses have a distinct and Exceptional role in healthcare
provide in interpersonal relationship. Meaning the application of Attitude and Skills among
clients and significant other.

Purpose- ​Promoting wellness restoring health and preventing illness. In Caring Out these
purposes it follows a process meaning there are series of action.

Process​- A series of action.

Nursing process-​Series of action. Is a systematic rational method of Planning and providing

individualize nursing care.

Purposes:

● Identify​ health status and actual or potential healthcare problems or needs.

● Established​ plan to meet the identified needs.
● Deliver ​specific intervention to meet those needs.
The Client may be an individual, family community or group.
-Nursing process have distinctive characteristic to be able to identify the changing health status
of the client. This characteristic includes cyclic and dynamic nature. ​Client centered nurse
focus on decision making ​interpersonal and Collaborative style ​universal Ability and the use of
critical thinking And clinical reasoning.

- Nursing process is a regularly repeated event or sequence of events So it is a cycle that is

continuously changing​ rather than staying static hence it is flexible.

-Furthermore nursing process is a ​patient-centered The nurse organizes the plan of care
according to the client problems rather than the nursing copes.
- The nursing process is an adaptation problem-solving and System theory. So it can be viewed
as parallel to But not separate from the process usually physician. Both processes the medical
and nursing begin with data gathering.
- Also this action or the intervention treatment or a problem statement Is the nursing diagnosis
for nursing and medical diagnosis for doctors. However, the medical model focuses on
physiological systems and disease process. Whereas the nursing process is directed toward a
clients to a real and potential diseases and illnesess. So the nursing process is interpersonal
and collaborative it requires the nurse to communicate directly to the client And find a ways to
meet their needs.
-It is also requires that nurses collaborate as providers of the health care team and a joint effort
to provide quality client care.
- The ​universally applicable characteristic The nursing process means that Is used as
framework for nursing care In all types of healthcare settings and clients of all age.

Phases or steps of nursing process

-​Are not separate entities but overlapping in a continuing sub processes.

Assessment
is the first and most critical phase of the nursing process. Cared out during implement and
evaluating process.
- A systematic and continuous collection, organization, validation, and documentation of
clients data. Its purpose is to establish a database about the client responds to health
concerns or illness. Example is when the patients arrived in the emergency room, we do
assessment to know the reason for admission. Also, when we are checking our patient
and asking our client to describe how they feel this part of assessment.
-For instance while the nurse is administering
- Although the assessment phase of the nursing process precedes the other phases in the
formal nursing process, be aware that assessment is ongoing and continuous throughout all
phases of the nursing process.
- The nursing process should be thought of as circular, not linear.

Diagnosis
- After we gather the data, the nurse analyze and synthesize the data to formulate the
nursing diagnosis, so the nurse sorts, cluster, and analyze data.
A. To be able to identify actual and potential problems and strengths.
B. Also, to write a precise statement problems and the factors.
C. While synthesizing the data, the nurse priorities the problems, which one needs
attention the most.

Planning
- In planning the nurse determine how to prevent, reduce or resolve the identified priority
client problems.
- So, its purpose is to develop an individualize care client that specifies the clients
growths, and desired outcomes and related nursing intervention.

Implementation
- Caring out and documenting client in the plan nursing intervention​.

Evaluation
-​Measured the degree to which the goals or outcome had been achieved.

B. Health Assessment in nursing practice

Nursing – ​the protection, promotion, and optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families, communities and populations.
(Nursing: Scope and Standards of Nursing Practice (American Nurses Association (ANA), 2010)
-The emphasize is base on diagnosis and treatment of the human responses, base on accurate
client assessment including how effective nursing interventions are to promote health and
prevent illness and injury.

Nursing Scope and Standards of Practice Standard 1 – The RN collects comprehensive data
pertinent to the patient’s health or situation. (ANA p.21)

To accomplish this pertinent and comprehensive data collection, the nurse:

● Collects data in a systematic and ongoing process.
● Involves the patient, family, other health care providers, and environment, as
appropriate, in holistic data collection.
● Prioritizes data collection activities based on the patient’s immediate condition, or
anticipated needs of the patient or situation.
● Uses appropriate evidence-based assessment techniques and instruments in collecting
pertinent data.
● Uses analytical models and problem-solving tools
● Synthesizes available data, information, and knowledge relevant to the situation to
identify patterns and variances.
● Documents relevant data in an retrievable format (ANA 2010, p.21)

Nursing Scope and Standards of Practice Standard 2 – The RN analyses the assessment
data to determine the diagnosis or issues.
To accomplish this, the RN:
● Derives the diagnosis or issues based on assessment data.
● Validates the diagnosis or issues with the client, family, and other healthcare providers
when possible and appropriate.
● Documents diagnosis or issues in a manner that facilitates the determination of the
expected outcomes and plan (ANA, 2010, p.22)

TYPES OF HEALTH ASSESSMENT

- Initial comprehensive assessment
- Ongoing or partial assessment
- Focused or problem-oriented assessment
- Emergency assessment
- Each assessment type varies according to the amount and type of data collected.

​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.
- Regardless of who collects the data the total health assessment subjective and objective
data regarding functional health environments system 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.
- The frequency of comprehensive assessment depends on the clients: 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​.
- 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.
- usually performed whenever the nurse or another health care professional has an
encounter with the client. Frequency of this health assessment will determine the acquity
of the client.
- Ex. 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
nursing focusing on the color and temperature of the extremities to determine the level of
oxygen.
Focused or Problem-Oriented Assessment
- does not replace the comprehensive health assessment. ​An ongoing process.
- performed when a ​comprehensive database exists ​for a client who comes to the health care
agency with a specific health concern.
- consists of a ​thorough assessment ​of a particular client problem and does not cover areas not
related to the problem.
- Determine the ​status of a specific problem identified. ​Also, ​identify new or overlooked
problems.
- ​Allow the nurse to broaden the database or to​ confirm the validity ​of the data obtain.
- Ex. 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.
- Example: Hourly assessment of a clients fluid intake and urinary output in an ICU. Assessment
of clients ability to perform self-care while assisting client to bath.

​Emergency Assessment
- a very rapid assessment performed in life-threatening situations.IN such situation of cardiac
arrest, and immediate assessment is needed to provide a prompt treatment.
- Ex. choking, cardiac arrest, drowning
- Check for ABCs.
 C. Nurses role in Health Assessment.
- Physical assessment has been an integral part of nursing, since the base of Florence
Nightingale. The nurses role in health assessment has changed significantly over the
years.
- In the 21st century the nurses role in assessment continue to expand becoming more
crucial than ever, so their role in assessment and diagnosis is more prevalent than ever
before in the history of nursing.

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 lims, body output and degrees of
nutrition, and hydration. (Florence Nigthingale)
- Palpation was used to measure pulse rate and quality to locate the fundus of the
puerperal woman.

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.
- Advanced practice nurses have been increasingly used in the hospital as clinical nurse
specialists and in the community as nurse practitioners.

Nurses role in Health Assessment

- A professional nurse should constantly observe situations and collect information to
make nursing judgements. It can occur no matter what the setting: hospital, clinic, home,
community or long-term care.

Different Role of the Nurses