HEALTH ASSESSMENT (LECTURE) - Collect data related to outcomes

PRELIMS - Compare data with outcomes

INTRODUCTION TO HEALTH ASSESSMENT - Relate nursing actions to client
> OVERVIEW OF NURSING PROCESS goals/outcomes
NURSING PROCESS (ADPIE) - Draw conclusions about problem
- It is the systematic, rational method of status
planning and providing nursing care. - Continue to modify or terminate
> Purpose the client’s care plan.
- To provide care for clients that is Assessment
individualized, holistic, effective and efficient. - A systematic and continuous
CHARACTERISTICS OF THE NURSING PROCESS collection, organization, validation,
• Cyclic and dynamic in nature interpretation, and documentation
• Client Centered of data.
• Adaptation of problem solving - Carried out during all the phases of
• Involves decision making the nursing process
• Interpersonal and collaborative 4 TYPES OF ASSESSMENT
• Universally applicable Type Time Purpose
• Uses critical thinking Performed
PHASES OF THE NURSING PROCESS Initial During To
A – ssessment admission establish a
D – iagnosis database
P – lanning Problem Ongoing To monitor
I – mplementation Focused process and/or
E – valuation identify a
1. Assessing specific,
- Collect data new, or
- Organize data overlooked
- Validate data problem
- Document data Emergency Emergency To identify
2. Diagnosing or crisis life-
- Analyze data threatening
- Identify health problems, risk, and problems
strength Time-Lapsed Several To
- Formulate diagnostic statements months compare a
3. Planning after initial client’s
- Prioritize problems/diagnoses assessment status over
- Formulate goals/desired outcomes a period of
- Select nursing interventions time
- Write nursing orders Activities During Assessment
4. Implementation 1. Data Collection
- Reassess the client 2. Validation of Data
- Determine the nurse’s need for 3. Organization of Data
assistance 4. Documentation of Data
- Implement the nursing Type of Data
interventions Subjective
- Supervise delegated case - Covert, symptoms
- Document nursing activities - Felt and experienced by the patient
5. Evaluation
 Objective Pattern excretory bowel
- Overt, signs function movement,
- Detected by an observer (bowel, voiding
bladder, and pattern, pain
Sources of Data skin). Includes on urination,
1. Primary – client client’s appearance of
2. Secondary – family members, perception of urine and
friends, health professionals, normal stool.
records. function
Methods of Data Collection Activity- Patterns of Exercise,
1. Observation Exercise exercise, hobbies, may
2. Interview Pattern activity, include
3. Physical Examination leisure, and cardiovascular
Data Verification recreation. and
- Data are validated whether respiratory
complete and accurate status,
Data Organization mobility, and
- Nurse organizes and clusters the activities of
information together to identify daily living.
areas of strengths and weaknesses. Cognitive Sensory- Vision,
Assessment Models perceptual perceptual hearing, taste,
1. Gordon’s 11 Functional Health pattern and cognitive touch, smell,
Patterns patterns pain
Functional Pattern Examples perception
Health Describes and
Pattern management;
Health Client’s Compliance cognitive
perception perceive with functions such
pattern of medication as language,
health and regimen, use memory, and
well being of health- decision
and how promotion making.
health is activities such Sleep-Rest Patterns of Client’s
managed. as regular Pattern sleep, rest, perception of
exercise, and quality and
annual check- relaxation. quantity of
ups. sleep and
Nutritional- Pattern of Condition of energy, sleep
metabolic food and fluid skin, teeth, aids, routines
pattern consumption haor, nails, client uses.
relative to mucous Self- Client’s self- Body comfort,
metabolic membranes; Perception concept body image,
need and height and Pattern pattern and feeling state,
pattern; weight. perceptions attitudes
indicators of of self. about self,
local nutrient perception of
supply. abilities,
Elimination Patterns of Frequency of objective data
 such as body 1. Orem’s Self-Care Model
posture, eye Self care
- dietary precautions
contact, voice - physical activities
- regular checkups
tone.
Role- Client’s Perception of Self Care Agency
Self Care Requisite
Relationship pattern of current major - lack of family support
- lack of awareness
- management and prevention
of HTN, Stress and Obesity
- unhealthy diet
role roles and
engagements responsibilities
Nursing Agency
and (e.g., father, - health education
- music theraphy
relationships husband, - mind diversion theraphy
- volunteers training

salesman); 2. Roy’s Adaptation Model

satisfaction
with family,
work, or social
relationships.
Sexuality- Patterns of Number and
Reproductive satisfaction histories of
and pregnancy and
dissatisfaction childbirth;
with sexuality difficulties
patter: with sexual
reproductive functioning;
pattern. satisfaction 3. Body System’s Model
with sexual ➢ Circulatory System
relationship ➢ Nervous System
➢ Respiratory System
Coping/Stress General Client’s usual
➢ Digestive System
Tolerance coping manner of
➢ Skeletal System
pattern and handling
➢ Muscular System
effective of stress,
the pattern in available
Data Documentation
terms of support
- Basis for determining quality of care
stress systems,
and should include appropriate data
tolerance perceived
to support identified problems.
ability to
COMPONENTS OF A NURSING CARE PLAN
control
manage Assess Nursi Goals Intervent Evalua
situations. ment ng and ions tion
Value Belief Patterns of Religious Diagn Objecti
values, beliefs affiliation, osis ves
(including what client Subjecti Probl Goal: First Met
spiritual), and perceives as ve em + Desire Format Partiall
goals that important in Cues: Etiolo d Indepen y Met
guide client’s life, value- Objecti gy Outco dent: Not
choices or belief conflicts ve mes: Depende Met
decisions. related to Cues: nt:
health, special Collabor
religious ative:
practices.
 Second - Collection of a subjective data:
Format o Past health history
Observat o Family History
ion o Lifestyle and Health
Preventi Practices
on - Objective Data – step by step
Intervent physical examination
ion 2. On Going or Partial Assessment
Treatme - Data collection that occurs after
nts comprehensive data base is
Health established
Promotio - Any problems previously detected
n were reassessed in less depth to
Intervent determine any major changes
ions 3. Focused or Problem Oriented
Assessment
- Performed when an
initial data base exists for a client.
- Thorough assessment
of a particular client problem.
4. Emergency Assessment
- Very rapid
assessment performed in life
threatening situations.
Nurse’s Role in Health Assessment
• Gather Information
• Nursing Diagnoses and Care
Planning
• Managing Problems
• Evaluation
• Discharge Teaching
• Advocate
Focus of Health Assessment in
Nursing
Conclusion: ➢ Collection of Subjective and
Assessment is the first and most critical step of objective data to determine a
nursing process. Accuracy of assessment data clients overall level of
affects all other phases of the nursing process. functioning in order to make a
A complete data base of both subjective and professional judgement
objective data allows the nurse to formulate ➢ The nurse performs a holistic
nursing diagnosis, develop client goals, and data collection.
intervenes, to promote health and prevent Framework for Health Assessment in Nursing
disease. • History of present health concerns
• Past health history
FOUR BASIC TYPES OF ASSESSMENT • Family history
1. Initial Comprehensive Assessment • Lifestyle and health practices
- Total health assessment when a • Examination of particular body part or
client first enters a health system system.
Lesson 2: Guidelines of an Effective Interview
and Health History
Subjective Data
- Can be elicited and verified only by
the client
- Provides clues to possible
physiologic, psychologic, and
sociologic problems
- Obtained through interviewing
o Sensations
o Feelings
o Perceptions
o Desires
o Preferences
o Beliefs
o Ideas
o Values
o Personal Information
Interviewing
- The method of obtaining a valid
nursing health history
- Requires professional,
interpersonal, and interviewing
(communication) skills.
Focus of Nursing Interview:
➢ Establish rapport and trusting
relationship with the client.
➢ Gathering information on the
client’s developmental
psychological, physiologic,
sociocultural, and spiritual
statuses to identify strength
and weaknesses.
Phases of the Interview
1. Pre-interaction phase
- Starts when the nurse is given the
responsibility to start a therapeutic
relationship with a patient.
- Also includes the thought process,
planning, and feeling of a nurse
before the first meeting with the
patient.
Nurses’ responsibility in this phase:
➢ To become well known about
own feelings, fear, and fantasies
➢ Analyze professional strengths
and weaknesses
➢ Collect information about the
patient like demographic data,
occupational data, etc.
➢ Prepare a plan based on the
data before meeting.
2. Orientation phase
- Essential to develop rapport and
gain trust
- Explain purpose, reason for taking
notes and assure client
confidentiality of the information.
- Nurse initiates effective
communication.
3. Working phase
- Nurse elicits comments on
biographical data
- Reason for seeking care
- History of present health concern
- Past health history
- Family history
- Review of body system for current
health problems
- Lifestyle
- Health practices and developmental
level.
- Nurses uses critical thinking to
interpret and validate information
- Nurse and client collaborate to
identify the client’s problems and
goals.
4. Termination phase
- Summary and closing phase
- Nurses summarizes information
- Identifies with client possible plans
to resolve the identified problems.
Communication During the Interview
Pointers to consider in non-verbal
communication
• Appearance
• Demeanor/Behavior
• Facial Expression
• Attitude
• Silence
• Listening
Verbal Communication
• Open ended questions
- Used to elicit the client’s feelings
and perceptions
 - Typically starts with ‘how’ or ‘what’
- Encourage description
- May reveal data about the client’s
health status
Advantages of Open-Ended Questions
➢ Allow for unlimited responses
➢ Provide more detail
➢ Deliver more insights
➢ Offer deeper qualitative data
➢ Give you sentiment and
opinions
➢ follow the whole customer
journey.
Examples:
▪ “How have you been feeling
lately?”
▪ “What do you feel about going
to chemo twice a week?”
• Close ended questions
- Used to obtain facts and to focus on
specific information
- Typically begins with ‘when’ or ‘did’
- Can be used to clarify or obtain
more accurate information about
issue disclosed in response to open
ended question.
Examples:
▪ ‘’When was the first time you felt
this pain in your abdomen?’’
▪ ‘’Did you consult?’’
▪ ‘’Did you find relief on the
medication prescribed?’’
“Open questions are used for deeper
discussion”
Other Effective Means to Communicate
Special Considerations:
➢ Age
➢ Culture
➢ Emotional Variations
• Laundry List
- Choice of words to choose from
- “Is the pain sever, dull, sharp, mild,
cutting or piercing”?
• Rephrasing
- Clarify the information the client is
providing
- Client: I’m really tired and
nauseated for two months and I
feel that I have some horrible
diseases
- Nurse: You are thinking you have a
serious illness.
• Well Placed Phrases
- Encouragement skill
- ‘Um-hum’
- ‘yes’
- ‘I agree’
• Inferring
- Do not lead rather get more
information
- Mrs. J: I have bad pain in my
stomach
- Nurse (notices has her hand on the
right side of her abdomen) “It
seems you have more difficulty with
the right side of your stomach”
• Providing Information
- Make sure to answer every
question as well as you can
- Be honest if do not know the
answer.
• Focus Question
- More specific toward the problem
- Nurse: so, you woke up short of
breath; has this happened before?
How to deal with anxious, angry, depressed,
and manipulative patients?
▪ Anxious
- Structure info, explain who you are,
your role, and purpose of visit
- Questions = simple/concise
- Nurse needs to stay relax
- Do not hurry, decrease external
stimuli
▪ Angry
- Calm, in control mannerisms and
tone
o Let patient vent
o If excessive, do not touch or
argue back
- Obtain info from other health
professionals as much as needed
- Do not argue back; provide
personal space
▪ Depressed
 - Show interest and understanding to
client and situation
- Do not be upbeat or encouraging
▪ Manipulative
- Provide structure and limitations
- Fine line b/ with manipulative and
reasonable requests
THERAPEUTIC COMMUNICATION
Communication
- A critical skill for nursing
- It is the proves by which humans
meet their survival needs, build
relationships, experience emotions.
- A dynamic process used to gather
assessment data, to teach and
persuade, and to express caring and
comfort. (in nursing)
- An integral part of the helping
relationship.
Modes of Communication
1. Verbal Communication
• Pace and Intonation
• Simplicity
• Clarity and Brevity
• Timing and Relevance
• Adaptability
• Credibility
• Humor
2. Nonverbal Communication
• Personal appearance
• Posture and gait
• Facial expressions
• Gestures
Therapeutic Communication
- Promote understanding
- Can help establish a constructive
relationship between the nurse and
the clients.
➢ Unlike the social relationship,
where they may not be a
specific purpose or direction,
the therapeutic helping
relationship is client and goal
oriented.
• Using Silence
- Accepting pauses or silences that
may extend for several seconds or
minutes without interjecting nay
verbal response.
• Providing General Leads
- Using statements or questions that :
a. Encourage the client to
verbalize
b. Choose a topic of
conversation
c. Facilitate continued
verbalization
• Being Specific and Tentative
- Making statements that are specific
rather than general, and tentative
rather than absolute.
• Using open-ended questions
- Asking broad questions that lead or
invite the client to explore
(elaborate, clarify, describe,
compare, or illustrate) thoughts or
feelings.
- Open ended questions specific only
to the topic to be discussed or
invite answers tat are no longer
than one or two words.
• Using Touch
- Providing appropriate forms of
touch to reinforce caring feelings.
• Restating or Paraphrasing
- Actively listening for the client’s
basic message and the repeating
those thoughts and/ or feelings in
similar words.
• Seeking Clarification
- A method of making the client’s
broad overall meaning of the
message more understandable.
• Perception checking or seeking
consensual validation
- Method similar to clarifying that
verifies the meaning of specific
words rather than the overall
meaning of a message.
• Offering Self
- Suggesting one’s presence interest
or wish to understand the client
without making any demands or
attaching conditions that the client
must comply with to receive the
nurse’s attention.
• Giving Information
- Providing, in a simple or direct
manner, specific factual information
the may or may not request.
- When information is not known,
the nurse states this and indicates
who has it or when the nurse will
obtain it.
• Acknowledging
- Giving recognition in a non-
judgmental way, in a change of
behavior, an effort the client has
made, or a contribution to a
communication.
- It may with or without
understanding, verbal or non-verbal
• Clarifying time or Sequencing
- Helping the client clarify an event,
situation, or happening in
relationship to time.
• Presenting Reality
- Helping the client to differentiate
the real from the unreal.
• Focusing
- Helping the client expand on and
develop a topic of importance.
• Reflecting
- Directing ideas, feelings, questions,
or content back to clients to enable
them to explore their own ideas
and feeling about the situation.
• Summarizing and Planning
- Stating the main points of a
discussion to clarify the relevant
points discussed.
Non-Therapeutic Communication
• Passing Judgment
- Giving opinions and approving or
disapproving responses, moralizing,
or implying one’s own values.
- These responses imply that the
client must think as the nurse
thinks, fostering client’s
dependence.
• Being Defensive
- Attempting to protect a person or
health care services from negative
comments
• Challenging
- Giving a response that makes
clients out of curiosity rather than
with the intent to assist the client.
• Probing
- Asking for information chiefly out of
curiosity rather than with the intent
to assist the client.
• Giving common advice
- Telling the client what to do.
- These responses dent the client’s
right to be an equal part note that
giving expert rather than common
advise is therapeutic.
• Testing
- Asking questions that makes the
client admit to something.
• Rejecting
- Refusing to discuss certain topics
with the clients.
• Stereotyping
- Offering generalized and
oversimplified beliefs about groups
of people that are based on
experience too limited to be valid.
- Ex: “nice weather were having’’ ‘I’m
fine and how are you?’’
• Changing topics and subjects
- Directing the communication into
areas of self-interest rather than
considering the client’s concerns is
often a self-protective response to a
topic that cause anxiety.
- Ex: “ I want to die” N:”did your
parents visited you?”
• Agreeing and Disagreeing
- Judgmental process, agreeing and
disagreeing imply that the client is
either right or wrong and that the
nurse is in a position to judge this.
- Ex: “I’m glad that you..” “I’d rather
you wouldn’t”
• Unwarranted Reassurance
- Using clichés or comforting
statements of advice as a means to
reassure the client.
- Ex: “everything will be alright”
“Don’t worry it’s fine”