Health Assessment: Prelim

Definition of Nursing
- Emphasis is placed on "diagnosis and treatment of human responses" based on
"accurate client assessment".

Nursing Scope and Standards of Practice states that:

- "The registered nurse collects comprehensive data pertinent to the patient's health or
situation."
- To accomplish this pertinent and comprehensive data collection, the nurse:
- Collects data in a systematic and ongoing process
- Involves the patient, family, and other health care providers and environment, as
appropriate in holistic data collection
- Uses appropriate evidenced-based assessment techniques and instruments in
collecting pertinent data

Phases of Nursing Process

1. Assessment/Assess
- Collecting subjective and objective data
- Gather information about the patient's condition

2. Diagnosis/Diagnose
- Analyzing data to make a professional nursing judgment
- Identify the patient's problems

3. Planning/Plan
- Determine outcome criteria and develop a plan
- Set goals of care and desired outcomes and identify appropriate nursing actions

4. Implementation/Implement
- Carrying out the plan
- Perform the nursing actions identified in planning

5. Evaluation/Evaluate
- Assessing whether outcome criteria has been met and revising the plan as necessary
- Determine if goals and expected outcomes are achieved

Purposes of Nursing Health Assessment

- To collect subjective and objective data
- Determine a client's overall level of fixing
- In order to make a professional clinical judgment

The Nurse Collects data about the patient's:

 - Physiologic
- Psychological
- Sociocultural
- Developmental
- Spiritual

Holistic Data Collection

- Mind, Body, and Spirit
- Considered as interdependent factors that affect a person's level of health.

The Nurse focuses on:

- Client's Health Status affects his Activities of Daily Living (ADL) — how it affects his/her
health.

End Result of Health Assessment:

- Formulation of Nursing Diagnosis

Types of Assessment

1.Initial Comprehensive Assessment

- Involves collection of subjective data about the client's perception of her health of all
body parts or systems, past health history, family history, and lifestyle and health
practices.
- Objective data gathered during step-by-step Physical Examination
- When the client enters a health care system and periodically thereafter to establish
baseline data against which future health status changes can be measured and
compared.

2. Ongoing or Partial Assessment

- Consists of data collection that occurs after the comprehensive database is established
- Consists of: Mini-overview of client's body systems and holistic health patterns as a
follow-up on his health status
- Example:
- Hypertensive client - BP every hour
- Respiratory Distress - RR every 15 mins
- Diabetic Patient - HGT every 6 hours

3. Focused or Problem Oriented Assessment

- Thorough assessment of a particular client problems and does not cover areas not
related to the problem
- Example:
- Ear pain — pain, hearing loss, dizziness, ringing on the ear —- no question on
sexual functioning.
4. Emergency Assessment
- Very rapid assessment performed in life-threatening situations
- Examples:
- Choking
- Cardiac arrest
- Drowning
- Immediate Dx(diagnosis) is needed to provide prompt treatment.
- A — Airway, B — Breathing, C — Circulation, D — Disability, E — Exposure

Steps of Health Assessment

4 Phases of the Assessment Phase of the Nursing Process

1. Collection of the subjective data

2. Collection of the objective data
3. Validation of data
4. Documentation of data
● Overlapping

Assessment
1. Collect Data
2. Organize Data
3. Validate Data
4. Document Data

Preparation
(Before meeting the client)
1. Review the patient's record if available
- Useful, provides background about chronic diseases and gives clues how
present illness may impart on the client's activities of daily living.
- Client's medical diagnoses and progress notes.
- Verify what you read
- Review client status with other members of the healthcare team
- Be open-minded
- Avoid premature judgments that may alter your ability to collect accurate data
- Always learn

2. Take a minute or two to reflect on your own feelings regarding your initial encounter with
the client.
- Example: Client is a drug addict.
- Avoid biases, judgment, tendency to project your own feelings on the client
- Be objective and open as possible
- Examples: STD, Terminal illness, amputation, paralysis, early prognosis,
HIV, and abortion
 3. Obtain and organize materials that you will need for the assessment
- Guide to review questions
- Hx(history) interview
- PTS(Post-thrombotic syndrome) history
- Gather equipment
- Stethoscope
- Thermometer
- Otoscope

Collecting Subjective Data

Subjective Data - elicited and verified only by the patient's sensations or symptoms
- Feelings
- Perceptions
- Desires
- Preferences
- Beliefs
- Ideas
- Personal information

Areas of Subjective Data

1. Biological Information
- Name
- Age
- Religion
- Occupation, etc
2. Physical symptoms related to each body part or system
- Eyes
- Ears
- Abdomen, etc
3. Past Health History
4. Family History
5. Health and Lifestyle practices
- Practices that put the client at risk, nutrition, activity, and relationships

Collecting Objective Data

Includes:
- Physical characteristics (skin color, posture)
- Body functions (HR, RR)
- Appearance (dressing, hygiene)
- Behavior (mood, affect)
- Measurements (BP, T, Ht, Wt)
- Results of lab testing (x-ray, CBC)
Validating
- Serves to ensure that the assessment process is not ended before all relevant data have
been collected
- Helps to prevent documentation of inaccurate data

Documenting
- Forms the database
- Provides data for all other members of the healthcare team
- Thorough and accurate documentation — ensure valid conclusions are made when data
are analyzed.

Comparing Subjective and Objective Data

Description
1. Subjective - Data elicited and verified by the client
1. Objective - Data directly or indirectly observed through measurement

Sources
1. Subjective - Client, Family, Significant others. Client record. Other health care
professionals.
2. Objective - Observations and physical assessment findings of the nurse or other health
care professionals. Documentation of assessments made in the client records.
Observations made by the client’s family or significant others

Methods used to obtain data

1. Subjective - The client interview
2. Objective - Observation and physical examination

Skills needed to obtain data

1. Subjective - Interview and therapeutic communication skills. Caring ability and empathy.
Listening skills
2. Objective - Inspection Palpation Percussion Auscultation

Examples
1. Subjective - “I have a headache.” “It frightens me.” “I am not hungry.”
2. Objective - Respirations 16 per minute BP 180/100, apical pulse 80 and irregular X-ray
film reveals fractured pelvis

Read Box 1-1 Evolution of the Nurse's Role in Health Assessment

21st Century
- Forensic Nursing
- Nursing Informatics
- Acute care nurse
 - Critical care nurse
- Ambulatory care nurse
- Home health nursing
- Public health nursing
- Hospice nurse

Collecting Subjective Data

Subjective Data
- elicited and verified only by the client
- Provide clues to possible physiologic, psychologic, and sociologic problems
- Obtained through interviewing

Interviewing
2 Focuses
1. Establishing rapport and a trusting relationship with the client to elicit accurate and
meaningful information
2. Gather information.

Phase of Interview
1. Pre-Introductory Phase
- Review the medical record before meeting with the client
- Past history
- Reasons for seeking healthcare

2. Introductory Phase
- Introduces
- Explains the purpose of the interview
- Discusses the questions
- Explains the reasons for taking notes
- Assures the client's confidentiality
- Comfortable and privacy
- Develop trust and rapport
- Begin by conveying a sense of priority and interest in the client.

3. Working Phase
- Nurse elicits information
- Nurse listens, observes cues, and uses critical thinking skills to interpret and validate
info

4. Summary and Closing Phase

- Nurse summarizes information obtained during the working phase and validates
problems and goals with the client
- Identifies and discusses possible plans to resolve the problem
- Ask if anything else concerns the client and if there are any further questions
Communication during the Interview
1. Verbal Communication
1. Interviewing
2. Non-verbal communication
1. Appearance
2. Demeanor
3. Facial expression
4. Attitude
5. Silence
6. Listening

1. Non-verbal to Avoid
a. Excessive or Insufficient Eye contact
b. Distraction and Distance
2. Verbal to Avoid
Biased or Leading question
"You don't feel bad, do you?"
Rushing through the interview
Reading the questions

Verbal Communication
Open-Ended Questions
- Used to elicit feelings and perceptions
- "How" and "what"
- "How have you been feeling lately?"
- Require more than one word response from the client
- Reveal significant information

Closed-Ended Questions
- To obtain facts and to focus on specific info
- Client can respond with one or two words
- "When" or "did"
- Useful in keeping the interview on course
- To clarify or obtain more accurate data

Laundry List
- A choice of words to choose from in describing symptoms, conditions, or feelings
- Help to obtain specific answers
- "Is the pain severe, dull, sharp, mild, cutting or piercing"
- "Does the pain occur once every year, day, month, or hour?"
- Repeat the choices as necessary

Rephrasing
 - Clarify info
- Enables you and the client to reflect on what was said
- Mr. G tells you that he has been really tired and nauseated for 2 months and that he is
scared because he fears that he has some horrible disease
- Rephrase: "You are thinking that you have a serious disease?"

Well-Placed Phrase
- "Um-hum"
- "Yes"
- "I agree"

Inferring
- What the client tells you and what you observe
- Abdominal pain - note where the client places her hands

Providing Information
- Provide the client with info as questions and concerns arise
- Answers questions
- Do not know the answer - tell the client that you will find out
- Knowledgeable - participative

When speaking with Elderly

- HEARING
- Speak slowly
- May be interpreted as mental slowness
- Face client
- Do not yell
- Position - on the side with better hearing
- Speak clearly
- Simple terms
- No slang

Complete Health History

- Excellent way to begin the assessment
- Lay the groundwork for identifying any problems and provides focus for the PE
- Provide information that will assist the examiner in identifying areas of strength and
limitation
- Provide specific cues to Health problems that are most apparent to the client

8 Sections
- Biographical data
- Reasons for seeking healthcare
- History of present health concern
- Past health history
 - Family health history
- Review of body system
- Lifestyle and health practices profile
- Developmental level

Biographical Data
- Information that identifies the client
- Sharing the information
- delete address and phone number
- Use initials
- Privacy
- Source of information - to determine accuracy
- Culture, ethnicity, religion, marital stud etc
- Special needs and beliefs that may affect the client's healthcare
- Educational level, occupation, working status - the client's level of understanding
- Client's strength and weaknesses, limitations
- Who lives with the client - caregiver and support

Reasons for Seeking Healthcare

- "What is your major concern or health problem at this time?"
- "How do you feel about having to see health care?"
- "Why are you here?"
- "How can I help you?"

History of Present Health Concern

- Detailed description of the concern
- Explain the health problem, symptom

C-O-L-D-S-P-A
Character: Describe the sign or symptom. How does it feel, look, sound, smell and so forth?
Onset: When did it begin?
Location: Where is it? Does it radiate?
Duration: How long does it last? Does it recur?
Severity: How bad is it?
Pattern: What makes it better? What makes it worse?
Associated Factors: What other symptoms occur with it?

Personal Health History

- Earliest beginning to present
- Childhood illnesses, immunizations, surgeries, accidents, allergies, use of prescription or
OTC drugs
- Hospitalization, pregnancies, births, injuries, emotional or psychiatric problems
- Pain experiences
- Nurse will identify risk factors
Family History
- Health problems that seem to run in the family and that are genetically based.
- Genetic predisposition
- Having grown up in a family and being exposed
- Smoking
- Exposure
- Negative role model
- Maternal, Paternal, Grandparents, etc
- Generation

Review of Systems
- Each body system is addressed
- Asked specific questions to elicit further details of the current health problems or from
recent past
- To include ONLY the client's subjective information and not the nurse's observations

Lifestyle and Health Practices

- Nutritional Habits
- Activity and exercise plan
- Sleep and rest patterns
- Self-concept and self-care responsibilities
- Social and community activities
- Relationships
- Values and belief systems
- Education and work
- Stress level and coping style
- Environment