INTRODUCTION TO

HEALTH ASSESSMENT
 INTRODUCTION TO
HEALTH ASSESSMENT
• 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” American
Nurses Association (2010).
 INTRODUCTION TO
HEALTH ASSESSMENT
• Emphasis is placed on “diagnosis and
treatment of human responses” based
on “accurate client assessment”,
including how effective nursing
interventions are “to promote health
and prevent illness and injury”
 INTRODUCTION TO
HEALTH ASSESSMENT
To accomplish this pertinent and comprehensive
data collection, the nurse:
1.Collects data in a systematic and
ongoing process
2. Involves the Patient, family,
other health care providers, and
environment, as appropriate, in a
holistic data collection
 INTRODUCTION TO
HEALTH ASSESSMENT
3. Prioritizes data collection activities based
on the patient’s immediate condition, or
anticipated needs of the patient and situation
4. Uses appropriate
evidence-based assessment
techniques and instruments in
collecting pertinent data
5. Uses analytical models and
problem-solving tools
 INTRODUCTION TO
HEALTH ASSESSMENT
6. Synthesizes available data,
information, and knowledge relevant to
the situation to identify patterns and
variances
7. Documents relevant data in a
retrievable format
 INTRODUCTION TO
HEALTH ASSESSMENT
8. Derives the diagnosis or issues based
on assessment data
9. Validates the diagnosis or issues in a
manner that facilitates the determination
of the expected outcomes and plan
Overview of Nursing Process
(ADPIE)
• Assessment is the first and most
critical phase of the nursing process.
• If data collection is inadequate
or inaccurate, incorrect nursing
judgements may be made that
adversely affect the remaining
phases of the process; diagnosis,
planning, implementation, and evaluation.
Overview of Nursing Process
(ADPIE)
• 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.
Overview of Nursing Process
(ADPIE)
• Health assessment is more than just
gathering information about the health
status of the client. It is analyzing the
data, making judgments about the
effectiveness of nursing interventions,
and evaluating client care outcomes.
Overview of Nursing Process
(ADPIE)
Overview of Nursing Process
(ADPIE)
• Each step of the nursing process depends on
the accuracy of the preceding step.
• Evaluation involves examining all the previous
steps, it especially focuses on achieving
desired outcomes.
• The arrow between assessment and evaluation
goes in both directions because they are
ongoing processes as well as separate phases.
Overview of Nursing Process
(ADPIE)
• When the outcomes are not as
anticipated, the nurse needs to revisit
all the steps, collect new data, and
formulate adjustments to the plan of
care.
Overview of Nursing Process
(ADPIE)
• The term Nursing
Process was first used/
mentioned by Lydia
Hall, a nursing theorist,
in 1955 wherein she
introduced 3 STEPs:
observation,
administration of care
and validation.
Overview of Nursing Process
(ADPIE)
• Nursing process
continue to
evolve: it used to
be a 3-step
process, then a
4-step process
(APIE), then a 5-
step (ADPIE),
and 6-step
process
(ADOPIE)
Overview of Nursing Process
(ADPIE)
Definition
•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.
Overview of Nursing Process
(ADPIE)
• It is a G O S H approach (goal-oriented,
organized, systematic and humanistic care) for
efficient and effective provision of nursing
care.
• Goal-oriented – nurse make her
objective based on client’s health needs.
• Remember: Goals and plan of care should be
base according to clients problems/needs NOT
according to your own problem as the nurse.
Overview of Nursing Process
(ADPIE)
• Organized/Systematic – the nursing process
is composed of sequential and interrelated
steps
• Humanistic care - Plan to care is developed
and implemented taking into consideration
the unique needs of the individual client.
• plan of care is individualized
• in providing care, it involves respect of
human dignity
Overview of Nursing Process
(ADPIE)
• Efficient – plan of care is relevant/ related to
the needs of the client thereby promoting
client satisfaction and progress.
• Effective – in planning care, utilized resources
wisely (staff, time, money/cost)
Overview of Nursing Process
(ADPIE)
Other characteristic of
Nursing Process:
•Cyclic and Dynamic in
nature – data from each
phase provides the input into
the next phase so that is
becomes a sequence of
events (cycle) that are
constantly changing
(dynamic) base on client’s
health status.
Overview of Nursing Process
(ADPIE)
• Involves skill in Decision-making – nurse
makes important decisions related to client
care, she choose the best action/steps to
meet a desired goal or to solve a problem.
She must make decisions whenever several
choices or options are available.
Overview of Nursing Process
(ADPIE)
• Uses Critical Thinking skills – the
nurse may encounter new ideas or
less-than-routine or non-ordinary
situations where decisions must be
made using critical thinking.
Overview of Nursing Process
(ADPIE)
Purpose of Nursing Process:
•To identify a client’s health status; his
Actual/Present and potential/possible
health problems or needs.
•To establish a plan of care to meet
identified needs.
•To provide nursing interventions to
meet those needs.
Overview of Nursing Process
(ADPIE)
• To provide an individualized, holistic,
effective and efficient nursing care.
Health Assessment in Nursing
Practice
• The purpose of a nursing assessment is to
collect holistic subjective and objective data to
determine a client’s overall level of
functioning in order to make a professional
clinical judgement.
• The nurse collects physiologic, psychological,
sociocultural, developmental, and spiritual
data about the client.
Thus, the nurse performs holistic
data collection.
Health Assessment in Nursing
Practice
• The mind, body, and spirit are
considered to be interdependent
factors that affect a person’s level
of health.
• The nurse in particular, focuses on
how the client’s health status
affects the client’s health.
• The nurse assess how clients
interact within their family and
community, and how the client’s
health status affects the family and
community.
Types of Health Assessment
A. Initial Comprehensive Assessment
•It 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 as well as objective data gathered
during a step-by-step
physical examination.
 Types of Health Assessment
Initial Comprehensive Assessment
• The nurse typically collects subjective data and
objective data in many settings.
• Depending on the setting, other members of the
health care team may also participate in various
parts of the data collection.
• In this setting, the nurse continuous to assess
the client as needed to monitor
progress and client outcomes.
 Types of Health Assessment
Initial Comprehensive Assessment
• Regardless of who collects the data, a total
health assessment is needed when the client
first enters a health care system and
periodically thereafter to establish baseline
data
• Frequency of comprehensive assessment
depends on the client’s age, risk factors,
health status, health promotion
practices, and lifestyle.
 Types of Health Assessment
On-going or Partial Assessment
• It consists of data
collection that occurs after
the comprehensive
database is established.
• This consist of a
minioverview of the
client’s body systems and
holistic health patterns as
a follow up on health
status.
 Types of Health Assessment
On-going or Partial Assessment
• Any problem 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.
 Types of Health Assessment
On-going or Partial Assessment
• A brief reassessment of the client’s body
system or holistic health patterns is
performed to detect any problems.
• This type of assessment is usually
performed whenever and wherever the nurse
or other health professional has an
encounter with the client
Types of Health Assessment
Focused or Problem-oriented 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 address
areas not related to the problem.
Types of Health Assessment
Focused or Problem-oriented Assessment
• At this time, it would not be
appropriate to perform a
comprehensive assessment by
repeating all system
examinations such as the heart
and neck vessels or abdominal
assessment.
Types of Health Assessment
Emergency assessment
• An emergency assessment is a very
rapid assessment performed in a
life threatening situations.
• An immediate assessment is needed
to provide prompt treatment.
• 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 nurse’s role in health assessment has
changed significantly over the years.
• The future will see increased specialization
and diversity of assessment skills for nurses.
While client acuity increases technology
advances, bedside nurses are challenged to
make in-depth physiologic and
psychosocial assessment while
correlating clinical data from
multiple technical monitoring devices.
Nurse’s Role in Health
Assessment
1. Acute Care Nurse – performs a focused
assessment, and then incorporates assessment
findings with a multidisciplinary team to
develop a comprehensive plan of care
2. Critical care outreach nurses – need enhanced
assessment skills to safely assess critically ill
clients who are
outside the structured intensive
care environment
Nurse’s Role in Health
Assessment
3. Ambulatory care nurses – asses and screen
clients to determine the need for physician
referrals
4. home health nurses – make independent
nursing diagnoses and referrals for collaborative
problem as needed
5. Public health nurses – assess the
needs of communities
Nurse’s Role in Health
Assessment
6. School nurses – monitor the growth and
health of children
7. hospice nurses - assess the needs of the
terminally ill clients and their families
Evolution of Nurse’s role in
health assessment
Late 1800s-Early 1900s
•Nurse’s relied on their
natural sense, 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.
Evolution of Nurse’s role in
health assessment
• Palpation was used
to measure pulse rate
and quality and to
locate the fundus of
the puerperal woman
Evolution of Nurse’s role in
health assessment
1930-1949
•The American Journal of Public Health
documents routine client and home inspection
by public health nurses
•This role of case finding, prevention of
communicable diseases, and routine use of
assessment skills in poor inner city areas were
performed
Evolution of Nurse’s role in
health assessment
1950-1969
•Nurse were hired to
conduct pre-
employment health
histories and physical
examinations for major
companies
Evolution of Nurse’s role in
health assessment
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
assessment
Evolution of Nurse’s role in
health assessment
• 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.
Evolution of Nurse’s role in
health assessment
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 nurse’s role in holistic
assessment.
Evolution of Nurse’s role in
health assessment
• Advanced practice
nurses have been
increasingly used in
the hospital as
clinical nurse
specialists and in
the community as
nurse practitioners.
Evolution of Nurse’s role in
health assessment
• The following factors will continue to promote
opportunities for nurses
➢ Rising educational costs and increased focus
on primary care that affect the numbers and
availability of medical students
➢ Increasing complexity of acute care
➢ Growing aging population with
complex morbidities
➢ Expanding health care needs of single parents
Evolution of Nurse’s role in
health assessment
➢ Increasing impact of children and the
homeless on communities
➢ Intensifying mental health issues
➢ Expanding health service networks
➢ Increasing reimbursement for health
promotion and preventive care services
➢ Limited number of medical students
pursuing practice in primary care
settings
Thank you