WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

INTRODUCTION TO HEALTH ASSESSMENT

Health assessment is the systematic process of gathering and analyzing subjective

and objective data about an individual's health status to identify actual or potential health
problems, establish a baseline for health promotion, and facilitate the development of an
appropriate plan of care.

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.
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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.

A. OVERVIEW OF 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.
o ✓ G - oal oriented
o ✓ O - rganized
o ✓ S - ystematic
o ✓ H - umanistic care

ASSESSMENT: STEP 1 OF THE NURSING PROCESS

• Assessment is the initial and most crucial phase of the nursing process.
• Inadequate or inaccurate data collection can lead to incorrect clinical judgments,
impacting subsequent phases: diagnosis, planning, implementation, and evaluation.
• Nurses' clinical judgment refers to the comprehensive process of synthesizing
information, interpreting cues, making decisions, and taking appropriate actions in the
provision of nursing care. It involves critical thinking, reasoning, and the application
of nursing knowledge and experience to achieve optimal client outcomes.
• Assessment is ongoing and continuous throughout all phases of the nursing process.
• Health assessment involves analyzing and synthesizing data, making judgments about
nursing interventions' effectiveness, and evaluating client care outcomes.
• The nursing process is circular, not linear, emphasizing the interdependence of its
steps.
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• Evaluation focuses on achieving desired outcomes and involves examining all

previous steps.
• Assessment and evaluation are ongoing processes as well as distinct phases, with a
continuous feedback loop.
• If outcomes are not as anticipated, the nurse must revisit all steps, collect new data,
and adjust the plan of care accordingly.

PHASES OF THE NURSING PROCESS

5 steps of the Nursing Process (ADPIE)

1. ASSESSMENT
2. DIAGNOSIS
3. PLANNING
4. INTERVENTION
5. EVALUATION

1. 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

This phase involves gathering subjective and objective data about the client's health
status. Subjective data are what the client expresses or feels, while objective data are
observable and measurable.

Example: A nurse conducts a comprehensive assessment of a patient admitted to the

hospital with chest pain. The nurse interviews the patient to gather subjective data
about the onset, location, and characteristics of the pain. Additionally, the nurse
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collects objective data by performing a physical examination, including vital signs,

auscultation of heart and lung sounds, and assessment of skin color and temperature.

2. 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.
o ✓ An actual nursing diagnosis identifies an occurring health problem for your
patient.
o ✓ A potential nursing diagnosis identifies a high-risk health problem that most
likely will occur unless preventive measures are taken.
o ✓ A possible nursing diagnosis is one that needs further data to support it
• Types of Nursing Diagnosis
o 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
o 2. Risk ND
 Problem + Etiology
 Risk for infection related to surgical incision
o 3. Health Promotion ND
 Problem
 Grieving, Hopelessness
o 4. Syndrome ND
 Specific cluster of nursing diagnosis that occur together and have
similar nursing interventions to resolve the situation
• Defining Characteristics (Signs and Symptoms)
o ✓ Observable assessment cues such as patient behavior, physical signs
• Related Factor (Etiology)
o ✓ Etiological cause or causative factor for diagnosis

In this phase, the nurse analyzes the collected data to identify health problems, risks,
and strengths. Nursing diagnoses are clinical judgments about actual or potential
health problems.

Example: Based on the assessment findings, the nurse identifies the nursing diagnosis
of "Acute Pain related to myocardial ischemia" for the patient experiencing chest
pain. The nurse prioritizes this diagnosis due to its significance in the patient's current
health condition.

3. PLANNING

• Desired outcomes
• Appropriate interventions
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• Involves setting goals and outcomes

• Individualized plan of care for your patient is ready once diagnosis have been
prioritized
• Priority Setting
o ✓ Ordering of nursing diagnoses or patient problems using notions of urgency
and importance to establish a preferential order for nursing interventions
• Goals
o ✓ Broad statement that describes a desired change in a patient’s condition,
perceptions or behavior
o ✓ 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 (SMART)
o ✓ Specific
o ✓ Measurable
o ✓ Attainable
o ✓ Realistic
o ✓ Time-bound

During planning, the nurse collaborates with the client, family, and healthcare team to
develop a comprehensive care plan. This plan outlines goals, interventions, and
expected outcomes.

Example: The nurse develops a plan of care for the patient with chest pain. Goals
may include relieving pain, stabilizing vital signs, and preventing complications.
Interventions may include administering pain medications, monitoring cardiac status,
and providing education on lifestyle modifications.

4. IMPLEMENTATION/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
o ✓ Direct Care
• Direct intervention
• Interventions are treatment performed through interaction with patient
• Ex. Medication administration, VS checking, insertion of IFC
o ✓ Indirect Care
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• 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
o ✓ Independent
• Action that the nurse initiates without supervision or direction from
others
o ✓ Dependent
• Actions that require an order from a health care provider
o ✓ Collaborative
• Interdependent interventions
• Therapies that require the combined knowledge, skills, and expertise of
multiple health care providers

Implementation involves carrying out the planned interventions to achieve the

identified goals. Nurses prioritize interventions based on the client's needs and the
urgency of the situation.

Example: The nurse implements the plan of care by administering prescribed pain
medications, monitoring the patient's cardiac status, and providing emotional support.
Additionally, the nurse ensures that the patient follows dietary and activity
restrictions.

5. 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.

In this final phase, the nurse evaluates the effectiveness of the interventions in
achieving the desired outcomes. If outcomes are not met, the nurse revises the plan of
care accordingly.

Example: The nurse evaluates the patient's response to pain management

interventions by reassessing the intensity and frequency of chest pain. If the pain
persists despite medication administration, the nurse collaborates with the healthcare
team to adjust the treatment plan, such as modifying medication doses or exploring
alternative pain management strategies.

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.
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• 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. HEALTH ASSESSMENT IN NURSING PRACTICE

FOCUS OF HEALTH ASSESSMENT IN NURSING

The focus of health assessment in nursing is to gather comprehensive subjective and

objective data to evaluate a client's overall health status and identify any actual or potential
health problems. This assessment encompasses various dimensions of health, including
physical, psychological, sociocultural, developmental, and spiritual aspects.

1. Physiological Aspect:
This aspect focuses on the client's physical health, including body systems, vital signs,
and any physical symptoms or conditions.

Example: The nurse assesses the client's vital signs (e.g., temperature, blood pressure,
heart rate, respiratory rate) and performs a physical examination to identify any
abnormalities or signs of illness.

2. Psychological Aspect:
This aspect considers the client's mental and emotional well-being, including
cognitive function, mood, coping mechanisms, and stress levels.

Example: The nurse assesses the client's mental status, asking questions to evaluate
cognitive function and observing for signs of anxiety, depression, or other
psychological distress.

3. Sociocultural Aspect:
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This aspect examines the client's social and cultural background, beliefs, values,
customs, family dynamics, and support systems.

Example: The nurse explores the client's cultural beliefs regarding health and illness,
dietary preferences, religious practices, and family roles to understand how these
factors influence their health behaviors and decision-making.

4. Developmental Aspect:
This aspect considers the client's stage of development across the lifespan, including
growth and maturation, developmental milestones, and age-specific health
considerations.

Example: For pediatric clients, the nurse assesses developmental milestones, growth
parameters, and age-appropriate behaviors. For elderly clients, the nurse evaluates
factors such as mobility, sensory changes, and cognitive decline.

5. Spiritual Aspect:
This aspect focuses on the client's spiritual beliefs, values, faith, sources of meaning,
and existential concerns.

Example: The nurse engages in therapeutic communication to explore the client's

spiritual beliefs, providing opportunities for prayer, meditation, or connection with a
spiritual leader if desired. The nurse also supports the client in finding meaning and
purpose in their health journey.

By conducting a holistic health assessment, nurses aim to understand the client's

unique health needs, strengths, and challenges, which guides them in providing
individualized and culturally sensitive care. The ultimate goal is to promote health, prevent
illness, and optimize the client's well-being through evidence-based nursing interventions and
patient education.

NURSING ASSESSMENT VS OTHER HEALTH CARE PROFESSIONALS’

ASSESSMENT

What makes nursing assessment unique is its holistic approach, which considers not
only the client's physiological status but also their psychological, sociocultural,
developmental, and spiritual dimensions. Unlike other healthcare professionals who may
focus primarily on specific aspects of health, such as physicians concentrating on
physiological status or physical therapists focusing on musculoskeletal systems, nursing
assessment integrates all these dimensions to provide comprehensive care.

Nurses gather both subjective and objective data through comprehensive health
histories, physical examinations, and observations. They focus on understanding the client's
responses to illness, coping mechanisms, health beliefs, values, and social support systems.
Nursing assessments inform nursing diagnoses, care planning, interventions, and evaluation,
aiming to address the client's holistic needs and promote well-being.
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TYPES OF NURSING ASSESSMENT

1. Initial Comprehensive Assessment

Collects subjective and objective data about the client's overall health status, including
past health history, family history, lifestyle, and physical examination. Establishes
baseline data for future comparisons and interventions.

Example: A nurse conducts an initial comprehensive assessment on a newly admitted

patient to a hospital. The nurse gathers subjective data regarding the patient's medical
history, current symptoms, past surgeries, family history of illnesses, and lifestyle
habits. Objective data are collected through a thorough physical examination,
including vital signs, neurological assessment, cardiovascular assessment, respiratory
assessment, abdominal assessment, and musculoskeletal assessment.

2. Ongoing Or Partial Assessment

Conducted after the comprehensive database is established. Monitors changes in the
client's health status, focusing on previously identified problems and detecting any
new issues. Frequency determined by the client's acuity and the setting.

Example: A nurse performs an ongoing or partial assessment on a patient admitted

with congestive heart failure. The nurse monitors the patient's vital signs, heart rate,
respiratory rate, and oxygen saturation at regular intervals to assess for any changes
indicating worsening heart failure or complications. The nurse also reassesses lung
sounds, peripheral edema, and fluid intake/output to monitor the patient's fluid status
and response to treatment.

3. Focused or Problem-Oriented Assessment

Conducted when a client presents with a specific health concern and a comprehensive
database already exists. Thoroughly assesses the problem area without addressing
unrelated aspects of health.

Example: A patient presents to the emergency department with complaints of

abdominal pain. The nurse conducts a focused or problem-oriented assessment
specifically targeting the abdomen. The nurse assesses the location, intensity, and
characteristics of the pain, inquires about associated symptoms such as nausea or
vomiting, and performs a focused abdominal examination to identify any potential
causes of the pain, such as appendicitis or gastrointestinal issues.

4. Emergency Assessment
Rapid assessment performed in life-threatening situations. Focuses on evaluating the
client's Airway, Breathing, and Circulation (ABCs) to provide immediate
treatment.

Example: A patient is brought to the emergency room after a motor vehicle accident
with suspected head trauma. The nurse performs an emergency assessment focusing
on the client's airway, breathing, and circulation (ABCs). The nurse quickly assesses
the patient's airway patency, breathing rate and effort, and circulation status, including
pulse rate, blood pressure, and skin color, to identify any life-threatening injuries or
conditions requiring immediate intervention.
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STEPS OF HEALTH ASSESSMENT

The assessment phase of the nursing process has four major steps:
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data

Overlapping Steps

While there are four distinct steps, they often overlap, and multiple steps may be performed
concurrently. For example, during the process of collecting subjective data from a client, the
nurse may observe objective indicators simultaneously. While the nurse asks the client about
their symptoms or medical history, they may also visually assess the client's physical
appearance, behavior, and other objective characteristics. If the client reports feeling anxious,
the nurse may observe signs of restlessness, increased heart rate, or rapid breathing—all of
which are objective data that validate the subjective report of anxiety.

Similarly, validation of data may occur concurrently with the collection of subjective and
objective data. As the nurse gathers information from the client, they may seek clarification
or confirmation of certain details to ensure accuracy. For instance, if the client mentions a
history of allergies, the nurse may ask follow-up questions to validate the specific allergens
and their reactions. This validation process can occur in real-time during the assessment,
preventing the documentation of inaccurate or incomplete data.

By allowing for overlapping and concurrent steps in the assessment process, nurses can
streamline the data collection process while maintaining thoroughness and accuracy. This
approach ensures that all relevant information is gathered efficiently, facilitating effective
clinical decision-making and providing a comprehensive basis for patient care planning and
intervention.

Preparing for the Assessment

1. Reviewing the Client's Medical Record:

• Before conducting the assessment, the nurse should review the client's medical
record, if available, to gather essential information.
• Biographical data, chronic diseases, medications, allergies, and past and
current health status are crucial for understanding the client's health
background.
• Information from the medical record, healthcare team members, and the
client's family provides valuable insights into the client's health status and
potential impacts on activities of daily living (ADLs).
2. Verification and Avoidance of Assumptions:
• It's important not to assume the accuracy of information found in the medical
record. Always verify details, such as allergies, directly with the client.
• Avoid premature judgments or assumptions about the client's knowledge or
needs. Stay open-minded to collect accurate data and make informed clinical
judgments.
3. Education and Self-Preparation:
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• Educate yourself about the client's diagnoses or tests, especially if unfamiliar,

to ensure a thorough understanding of the client's health status.
• Reflect on personal feelings and biases before the assessment, especially in
situations involving sensitive topics or diverse client populations, to maintain
objectivity and openness.
4. Gathering Necessary Materials:
• Obtain and organize assessment tools, interview guides, and documentation
forms required for the assessment process.
• In settings where electronic health records (EHRs) are used, familiarize
yourself with the system for recording data efficiently.
• Gather essential equipment, such as a stethoscope, thermometer, or otoscope,
necessary for performing a comprehensive nursing health assessment.

STEP 1: COLLECTING SUBJECTIVE DATA

1. Definition of Subjective Data

• Subjective data encompass sensations, symptoms, feelings, perceptions,
desires, preferences, beliefs, ideas, values, and personal information reported
by the client.
• These data can only be elicited and verified by the client during the
assessment process.

2. Effective Interviewing Skills:

• To obtain accurate subjective data, nurses must develop effective interviewing
skills suitable for diverse clients and settings.
• Creating a comfortable, relaxed atmosphere and being an attentive listener are
essential for conducting a successful clinical interview.

3. Major Areas of Subjective Data:

• Biographical Information: Includes name, age, religion, occupation, and
other demographic details.
o Name: John Smith
o Age: 45 years old
o Religion: Christianity
o Occupation: Accountant

• History of Present Health Concern: Involves identifying physical symptoms

related to each body part or system, such as issues with the eyes, ears,
abdomen, etc.
o Physical Symptoms Related to Each Body Part or System:
 Eyes: Blurred vision
 Ears: Ringing sensation (tinnitus)
 Abdomen: Persistent abdominal pain

• Personal Health History: Explores the client's past medical history, including
previous illnesses, surgeries, or chronic conditions.
o Previous medical conditions: Hypertension, diabetes
o Surgical history: Appendectomy at age 30
o Medication history: Lisinopril for hypertension
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• Family History: Investigates the health status of the client's family members,
including any hereditary or genetic conditions.
o Mother: Hypertension and diabetes
o Father: History of heart disease
o Siblings: No significant medical history

• Health and Lifestyle Practices: Covers health behaviors, practices, and

habits that may impact the client's well-being, including nutrition, activity
levels, relationships, cultural beliefs, family dynamics, and the community
environment.
o Health practices that put the client at risk: Smoking one pack of
cigarettes per day
o Nutrition: Consumes fast food frequently
o Activity: Exercises three times a week
o Relationships: Married with two children
o Cultural beliefs or practices: Vegetarian diet due to religious beliefs
o Family structure and function: Supportive family environment
o Community environment: Lives in a suburban neighborhood with
access to parks and recreational facilities

• Review of Systems: Addresses specific questions about various bodily

systems to assess for any additional symptoms or concerns.
o Respiratory: Shortness of breath on exertion
o Cardiovascular: Chest pain during exercise
o Gastrointestinal: Occasional indigestion after meals
o Neurological: Frequent headaches, especially in the mornings

STEP 2: COLLECTING OBJECTIVE DATA

1. Nature of Objective Data:

• Objective data are directly observable and measurable.
• They include physical characteristics, body functions, appearance, behavior,
measurements, and results of laboratory testing.

2. Examples of Objective Data:

a. Physical Characteristics:
• Skin color: Observing the skin's color can provide information about
circulation, oxygenation, and potential issues like jaundice or pallor.
• Posture: Assessing the alignment and positioning of the body can offer
clues about musculoskeletal health, balance, and potential issues like
spinal alignment or muscle tension.
b. Body Functions:
• Heart rate: Measuring the number of heartbeats per minute provides
insights into cardiac function, rhythm, and potential abnormalities such as
tachycardia or bradycardia.
• Respiratory rate: Counting the number of breaths taken per minute
reflects the efficiency of breathing and can indicate respiratory distress or
other respiratory issues.
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c. Appearance:
• Dress: Observing the clothing worn by the individual provides insights
into personal grooming habits, socioeconomic status, and cultural
preferences.
• Hygiene: Assessing cleanliness and personal grooming practices offers
insights into self-care habits, adherence to hygiene routines, and potential
concerns such as poor hygiene contributing to skin infections or body odor.
d. Behavior:
• Mood: Observing the individual's emotional state or overall disposition
provides insights into engagement in care, communication, and willingness
to participate in activities.
• Affect: Assessing the outward expression of mood through facial
expressions and body language helps evaluate the individual's demeanor,
responsiveness, and emotional expressiveness.
e. Measurements:
• Blood pressure: Measuring the force of blood against the walls of arteries
provides information about cardiovascular health, vascular resistance, and
risk of cardiovascular diseases.
• Temperature: Assessing the body's heat level offers insights into
metabolic activity, homeostasis, and potential health conditions such as
fever or hypothermia.
• Height and weight: Measuring physical dimensions provides information
about growth, development, nutritional status, and potential health risks
such as obesity or malnutrition.
f. Results of Laboratory Testing:
• Platelet count: Analyzing the concentration of platelets in the blood helps
diagnose bleeding disorders, clotting disorders, and conditions affecting
bone marrow function.
• X-ray findings: Interpreting imaging tests reveals bone fractures, joint
abnormalities, soft tissue injuries, or signs of underlying conditions such as
pneumonia or osteoarthritis.

3. Sources of Objective Data:

• Obtained through general observation and physical examination techniques
such as inspection, palpation, percussion, and auscultation.
• Medical/health records contain observations made by various healthcare
professionals.
• Observations noted by the client's family or significant others also contribute
to objective data collection.

4. Utilization of Objective Data:

• Objective data complement subjective data to provide a comprehensive
understanding of the client's health status.
• They serve as a basis for clinical judgments and decision-making in nursing
practice.
• Objective data help in evaluating the effectiveness of interventions and
monitoring changes in the client's condition over time.

STEP 3: VALIDATION OF ASSESSMENT DATA

1. Validation of Assessment Data:
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• Validation ensures that assessment data collected are accurate, complete, and
reliable. It is a critical step to prevent the documentation of inaccurate
information.
• This process typically occurs concurrently with the collection of subjective
and objective data, ensuring that no relevant information is overlooked or
misrepresented.

2. Types of Assessment Data to Validate:

• Both subjective and objective data should be validated. This includes
information provided by the client (subjective) and observations made by the
examiner (objective).
• Subjective data such as symptoms, feelings, and perceptions should be verified
with the client to confirm accuracy.
• Objective data such as physical characteristics, vital signs, and laboratory
results should be cross-checked with multiple sources or validated against
established norms.

3. Methods of Data Validation:

• Validation can be performed through various methods, including:
• Repeating questions or observations to ensure consistency and
accuracy.
• Comparing data with previous records or baseline measurements to
identify any discrepancies or changes.
• Seeking confirmation from other healthcare providers involved in the
client's care to validate findings.

4. Identifying Areas Where Data are Missing:

• Apart from confirming existing data, validation also involves identifying gaps
or areas where information is incomplete.
• Addressing missing data ensures a comprehensive assessment and prevents
oversight of crucial information that may influence clinical decisions.

5. Importance of Validation:
• Validating data enhances the reliability and credibility of the assessment
process, contributing to accurate diagnosis and effective care planning.
• It promotes thoroughness and professionalism in nursing practice, fostering
trust between healthcare providers and clients.

6. Collaborative Validation:
• Collaboration with other healthcare providers, is integral to the validation
process. It allows for a multidisciplinary approach to assessment, drawing on
diverse perspectives and expertise.
• Consulting colleagues or specialists can offer valuable insights and ensure a
comprehensive evaluation of the client's health status.

Validating assessment data is an essential component of the assessment process,

ensuring accuracy, completeness, and reliability of information gathered. It involves
confirming existing data, identifying any discrepancies, and addressing gaps to facilitate
informed clinical decision-making and optimal client care.
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STEP 4: DOCUMENTING DATA

1. Importance of Documenting Data:

• Documentation of assessment data serves as the foundation for the entire
nursing process, providing a comprehensive record of the client's health status,
interventions, and outcomes.
• It facilitates communication and collaboration among healthcare team
members, ensuring continuity of care and promoting patient safety.
• Thorough and accurate documentation is essential for making valid
conclusions during the analysis phase of the nursing process, guiding
subsequent decision-making and interventions.
2. Role in Nursing Process:
• Documented data forms the basis for nursing diagnoses, care planning,
implementation of interventions, and evaluation of outcomes.
• It helps track changes in the client's condition over time, enabling healthcare
providers to monitor progress and adjust care plans accordingly.
3. Types of Documentation:
• These may include electronic health records (EHRs), paper-based charts,
progress notes, nursing care plans, flow sheets, and incident reports.
4. Purpose of Documentation:
• Documentation serves multiple purposes, including legal, regulatory, and
accreditation requirements.
• It provides a legal record of the care provided, ensuring accountability and
protecting both healthcare providers and patients in case of litigation.
• Documentation also supports reimbursement for healthcare services by
providing evidence of the care delivered.
5. Content of Documentation:
• Nurses must document relevant subjective and objective data collected during
the assessment, as well as their interpretations, clinical judgments, and
interventions.
• Important aspects to document include the client's health history, current
symptoms, vital signs, physical examination findings, diagnostic test results,
nursing diagnoses, care plans, interventions, and client responses.
6. Guidelines for Documentation:
• Guidelines for documentation emphasize clarity, accuracy, objectivity,
completeness, and timeliness.
• Nurses should adhere to institutional policies and professional standards when
documenting, ensuring consistency and uniformity in documentation practices
across healthcare settings.
7. Role in Interdisciplinary Communication:
• Documented data serves as a means of communication not only within the
nursing team but also with other healthcare disciplines.
• It provides a comprehensive overview of the client's health status and care
needs, facilitating collaboration and coordination of care among different
healthcare providers.

Thorough and accurate documentation is a fundamental aspect of nursing practice,

playing a vital role in ensuring quality patient care, promoting patient safety, and meeting
regulatory requirements.
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ANALYZING CUES TO IDENTIFY CLIENT CONCERNS: STEP 2 OF THE

NURSING PROCESS

During the second phase of the nursing process, nurses analyze cues to determine
client concerns (nursing problem), collaborative concerns, or the need for referrals. This
analysis involves recognizing, analyzing, and synthesizing data to make informed clinical
judgments about the client's health.

1. Client Concerns (Nursing Problem): These are problems identified by nurses

regarding the health of an individual, family, group, or community. Nurses prioritize
these concerns to plan interventions and evaluate client outcomes.

Example: Mrs. Smith, a 65-year-old woman, presents with shortness of breath,

fatigue, and swelling in her ankles. Upon assessment, the nurse identifies a history of
heart failure and poor medication adherence. The nursing problem identified is
"Impaired Gas Exchange related to decreased cardiac output."

2. Collaborative Problems: These are physiological complications that nurses monitor

to detect changes in the client's status. Nurses manage collaborative problems by
implementing both physician- and nurse-prescribed interventions to prevent further
complications.

Example: Mr. Jones, a 50-year-old man, is admitted with acute kidney injury (AKI).
The nurse monitors Mr. Jones closely for signs of fluid overload, electrolyte
imbalances, and uremic complications. The collaborative problem identified is "Risk
for Fluid Volume Excess related to impaired renal function."

3. Referrals: Nurses may identify problems that require the assistance of other
healthcare professionals. Referrals are made to address the holistic needs of the client,
including physical, psychological, social, cultural, and spiritual aspects.

Example: Ms. Lee, a 30-year-old woman, is being treated for depression. During
assessment, the nurse discovers that Ms. Lee has expressed suicidal ideation.
Recognizing the seriousness of the situation, the nurse refers Ms. Lee to the hospital's
psychiatric team for immediate evaluation and intervention.

PROCESS OF DATA ANALYSIS

To identify client concerns, collaborative problems, or the need for referrals, nurses follow a
systematic process of data analysis. This process involves six major steps:

1. Identify abnormal cues and supportive cues:

Abnormal cues are deviations from the expected findings during assessment,
indicating potential health issues. Supportive cues are additional data that
corroborate or provide context for the abnormal findings.

Example: During a physical examination, the nurse notes that the patient has elevated
blood pressure (abnormal cue) and reports experiencing frequent headaches
(supportive cue).
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

2. Cluster cues to identify patterns or relationships:

Clustering involves organizing related cues together to identify patterns or

relationships between different pieces of data. This helps in recognizing common
themes or issues.
Example: The nurse observes that the patient has increased thirst, frequent urination,
and unintentional weight loss, which, when clustered together, suggest possible
symptoms of diabetes mellitus.

3. Draw inferences and identify and prioritize client concerns based on the data:
After analyzing the cues and their patterns, the nurse draws conclusions or inferences
about the client's health status. Based on these inferences, the nurse identifies and
prioritizes the client's concerns.

Example: Considering the abnormal blood pressure, frequent headaches, and

supportive cues indicating stress, the nurse infers that the client may be experiencing
hypertension. The prioritized client concern is "Risk for Hypertension-related
Complications."

4. Propose possible collaborative problems to notify the primary care provider:

Collaborative problems are potential health issues that require coordination between
healthcare providers. The nurse identifies these problems and notifies the primary care
provider for collaborative management.

Example: Based on the assessment findings, the nurse identifies the collaborative
problem "Risk for Falls related to orthostatic hypotension" and communicates this to
the primary care provider for inclusion in the care plan.

5. Identify the need for referral to other healthcare professionals if necessary:

If the assessment reveals health concerns beyond the nurse's scope of practice, referral
to other healthcare professionals becomes necessary for specialized evaluation or
treatment.

Example: If a patient presents with chest pain and other symptoms suggestive of a
myocardial infarction, the nurse promptly refers the patient to a cardiologist for
further evaluation and management.

6. Document conclusions reached during the analysis process:

Documenting the conclusions drawn during the analysis process is essential for
maintaining accurate records of the assessment findings and the resulting care plan.

Example: The nurse documents the identified client concerns, collaborative problems,
and any referrals made in the patient's electronic health record for reference by other
healthcare team members.

This systematic approach to data analysis requires diagnostic reasoning skills and critical
thinking to ensure accurate identification and prioritization of client concerns.
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

• Diagnostic Reasoning Skills: Diagnostic reasoning refers to the cognitive process

used by healthcare professionals to identify, analyze, and interpret relevant
information in order to reach a diagnosis or make clinical judgments about a patient's
health condition. It involves systematically collecting and assessing data, recognizing
patterns or abnormalities, formulating hypotheses, and determining the most likely
diagnosis or problem based on available evidence. Diagnostic reasoning skills are
essential for accurate clinical decision-making and effective patient care.
• Critical Thinking: Critical thinking is the ability to objectively analyze, evaluate, and
interpret information or situations in a logical and systematic manner. It involves
questioning assumptions, considering multiple perspectives, and applying evidence-
based reasoning to form judgments or make decisions. Critical thinking enables
individuals to identify biases, recognize logical fallacies, and weigh the validity and
relevance of information before drawing conclusions or taking action. In healthcare,
critical thinking skills are crucial for healthcare professionals to assess complex
situations, solve problems, and provide safe and effective care to patients.

EXAMPLE OF DIAGNOSTIC REASONING FOR NURSES

Scenario: A nurse is caring for a patient who has been experiencing episodes of chest pain.
1. Collecting Data:
• Subjective Data: The nurse interviews the patient to gather information about
the onset, duration, location, and severity of the chest pain. The nurse also asks
about any associated symptoms such as shortness of breath or nausea.
• Objective Data: The nurse performs a physical examination, assessing vital
signs, listening to heart and lung sounds, and checking for any signs of distress
or discomfort.
2. Analyzing Data:
• Abnormal Cues: The nurse notes that the patient's chest pain is sudden in
onset, radiates to the left arm, and is accompanied by diaphoresis (excessive
sweating) and shortness of breath.
• Supportive Cues: The patient has a history of hypertension and high
cholesterol, and family history reveals a father who experienced a heart attack
at a young age.
3. Drawing Inferences and Identifying Concerns:
• Based on the data analysis, the nurse infers that the patient may be
experiencing symptoms of acute myocardial infarction (heart attack). This
becomes the primary concern.
• The nurse prioritizes interventions aimed at alleviating the patient's chest pain,
stabilizing vital signs, and preventing further complications.
4. Collaboration and Referral:
• The nurse collaborates with the healthcare team, including the physician, to
notify them of the patient's condition and potential diagnosis.
• The nurse may initiate collaborative interventions such as administering
oxygen therapy and aspirin while awaiting further evaluation and treatment by
the physician.
5. Documentation:
• The nurse documents the assessment findings, interventions performed, patient
responses, and any communication with other healthcare providers. This
ensures continuity of care and provides a record of the diagnostic reasoning
process.
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

APPLICATION OF CRITICAL THINKING

In the scenario provided, nurses can apply critical thinking in several ways:
1. Assessment Interpretation: Nurses critically analyze the subjective and objective
data collected from the patient to identify patterns, anomalies, and potential
implications. For example, they recognize that the combination of sudden-onset chest
pain, radiation to the left arm, and diaphoresis may suggest cardiac involvement.
2. Problem Recognition: Critical thinking helps nurses recognize potential problems or
complications based on the assessment findings. In this scenario, nurses identify the
possibility of acute myocardial infarction (heart attack) as a primary concern and
prioritize interventions accordingly.
3. Decision-Making: Nurses use critical thinking to make decisions about the most
appropriate course of action for the patient's care. They weigh the risks and benefits of
interventions, consider available evidence-based practices, and adapt their plans based
on the patient's response and changing circumstances.
4. Collaboration and Communication: Critical thinking enables nurses to effectively
communicate with other members of the healthcare team and collaborate on patient
care. They share their assessments, interpretations, and concerns with physicians and
other providers, contributing valuable insights to the diagnostic and treatment process.
5. Reflection and Learning: After the patient's care is delivered, nurses engage in
critical reflection to evaluate the effectiveness of their interventions, consider
alternative approaches, and identify opportunities for improvement. This continuous
learning process enhances their clinical judgment and decision-making skills for
future cases.

FACTORS AFFECTING HEALTH ASSESSMENT

1. Cultural Background: Cultural beliefs, values, practices, and traditions significantly
influence an individual's health perceptions, behaviors, and responses to illness.
Understanding and respecting cultural diversity are crucial for accurate assessment
and effective communication.

Example:
An individual from a culture that values herbal remedies may prefer traditional
treatments over prescription medications. Therefore, a nurse should inquire about the
client's cultural beliefs and practices regarding healthcare to ensure treatment
adherence and effectiveness.

2. Family Dynamics: Family structure, relationships, and support systems impact an

individual's health and healthcare decisions. Assessing family dynamics provides
insights into the social support available to the individual and potential sources of
stress or conflict.

Example:
A client with a chronic illness may rely heavily on family members for caregiving and
emotional support. Understanding the family's dynamics, such as who assumes
caregiving responsibilities and how family roles influence decision-making, helps the
nurse develop a comprehensive care plan.
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

3. Community Resources: Access to healthcare services, socioeconomic conditions,

environmental factors, and community support networks affect health outcomes.
Assessing community resources helps identify barriers to healthcare access and
opportunities for collaboration with community organizations.

Example:
A client living in a rural area with limited access to healthcare facilities may face
challenges in accessing regular medical care. By assessing community resources, such
as local clinics, transportation services, and support groups, the nurse can assist the
client in navigating available services and advocate for additional resources if needed.

4. Socioeconomic Status: Income, education level, employment status, and living

conditions influence health behaviors, access to healthcare, and overall well-being.
Understanding socioeconomic factors helps nurses address social determinants of
health and advocate for resources to meet clients' needs.

Example:
A low-income individual may struggle to afford prescription medications or nutritious
food, leading to poor health outcomes. Assessing socioeconomic factors helps the
nurse identify financial barriers to healthcare access and collaborate with social
services to connect the client with financial assistance programs or food banks.

5. Health Literacy: Individuals' understanding of health information, ability to navigate

healthcare systems, and adherence to treatment plans are influenced by health literacy
levels. Assessing health literacy helps tailor communication strategies and educational
interventions to meet clients' needs effectively.

Example:
A client with limited health literacy may have difficulty understanding medical
instructions or interpreting health information. To address this, the nurse can use plain
language, visual aids, and teach-back methods to ensure the client comprehends the
information provided and can actively participate in their care.

6. Biopsychosocial Factors: Biological, psychological, and social factors interact to

influence health and illness. Assessing biopsychosocial factors involves evaluating
physical health, mental health, emotional well-being, and social support networks to
provide holistic care.

Example:
A client experiencing chronic pain may also struggle with depression and social
isolation. Assessing biopsychosocial factors involves evaluating the client's physical
symptoms, emotional well-being, social support network, and coping mechanisms to
develop a holistic treatment plan addressing all aspects of health.

7. Environmental Factors: Environmental hazards, such as pollution, unsafe living

conditions, and lack of access to clean water or nutritious food, impact health
outcomes. Assessing environmental factors helps identify risks to health and advocate
for environmental improvements to promote health equity.

Example:
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

A client living in an urban area with high air pollution levels may experience
exacerbations of respiratory conditions. Assessing environmental factors helps the
nurse identify environmental risks to health and educate the client on strategies to
minimize exposure, such as using air purifiers or avoiding outdoor activities during
peak pollution times.

8. Cultural Competence: Nurses' awareness of their own cultural biases, attitudes, and
values is crucial for conducting culturally sensitive assessments. Culturally competent
care involves recognizing and respecting diversity, adapting care practices to meet
clients' cultural preferences, and addressing healthcare disparities.

Example:
A nurse caring for a diverse patient population recognizes the importance of cultural
competence in providing effective care. For example, when caring for a Muslim
patient during Ramadan, the nurse respects fasting practices and schedules medication
administration accordingly, demonstrating cultural sensitivity and respect for the
client's beliefs.

C. THE 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
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

o Increasing reimbursement for health promotion and preventive care services

EVOLUTION OF THE NURSE’S ROLE IN HEALTH ASSESSMENT

• LATE 1800s–EARLY 1900s
o 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).
o Palpation was used to measure pulse rate and quality and to locate the fundus
of the puerperal woman (Fitzsimmons & Gallagher, 1978).
o Examples of independent nursing practice using inspection, palpation, and
auscultation have been recorded in nursing journals since 1901.
• 1930–1949
o The American Journal of Public Health documents routine client and home
inspection by public health nurses in the 1930s.
o 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
o 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
o 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).
o 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
o 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.
o 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.
o Advanced practice nurses have been increasingly used in the hospital as
clinical nurse specialists and in the community as nurse practitioners.

ROLES OF NURSES IN HEALTH ASSESSMENT:

1. Conducting thorough evaluations
Nurses are responsible for assessing patients' overall health status by conducting
comprehensive evaluations. This involves examining both subjective aspects, such as
symptoms reported by the patient, and objective data obtained through physical
examinations and diagnostic tests.
2. Collecting subjective and objective data
Nurses gather information from patients about their medical history, current
symptoms, and other subjective experiences. Additionally, they perform physical
assessments and interpret diagnostic results to obtain objective data about the patient's
health status.
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

Example:
A nurse interviews a patient to understand their symptoms of chest pain and shortness
of breath, conducts a physical examination to assess vital signs and lung sounds, and
orders diagnostic tests like an electrocardiogram to further evaluate the patient's
cardiac health.
3. Analyzing data and formulating nursing diagnoses
Nurses analyze the collected data to identify health problems and formulate nursing
diagnoses. This involves critical thinking to interpret the findings and determine the
patient's underlying health issues.
Example:
Based on assessment findings of elevated blood pressure, obesity, and poor dietary
habits, a nurse identifies the nursing diagnosis of "Risk for Hypertension related to
obesity and unhealthy dietary habits."
4. Developing individualized care plans
Nurses develop individualized care plans based on the assessment findings and
nursing diagnoses. These care plans outline specific interventions tailored to address
the patient's unique needs and promote optimal health outcomes.
Example:
A nurse creates a care plan for a diabetic patient that includes interventions such as
blood glucose monitoring, insulin administration, dietary modifications, and regular
exercise to manage blood sugar levels.
5. Collaborating with healthcare professionals
Nurses collaborate with other members of the healthcare team, including physicians,
therapists, and specialists, to ensure comprehensive patient care. This
multidisciplinary approach facilitates holistic assessment and management of patients'
health needs.
Example:
A nurse consults with a physical therapist to develop a rehabilitation plan for a patient
recovering from a stroke, incorporating both medical and therapeutic interventions to
optimize the patient's recovery.
6. Educating patients and families
Nurses play a crucial role in patient education, providing information about health
promotion, disease prevention, medication management, and self-care techniques. By
empowering patients and their families with knowledge, nurses support informed
decision-making and promote positive health behaviors.
Example: A nurse educates a diabetic patient about the importance of monitoring
blood sugar levels, administering insulin injections, following a healthy diet, and
recognizing signs of hyperglycemia or hypoglycemia to manage their condition
effectively.
7. Advocating for patients' holistic well-being
Nurses advocate for patients' holistic well-being by addressing their physical,
emotional, social, and spiritual needs. This involves advocating for patients' rights,
preferences, and access to quality healthcare services.
Example: A nurse advocates for a hospitalized patient's right to receive culturally
appropriate meals that align with their dietary preferences and religious beliefs,
ensuring that their nutritional needs are met while respecting their cultural and
spiritual values.
8. Observing patient responses and adjusting care plans
WORKTEXT 1 (HEALTH ASSESSMENT LECTURE)

Nurses continuously monitor patients' responses to interventions and adjust care plans
accordingly. This ongoing assessment and evaluation process allow nurses to address
changes in patients' conditions and optimize their care outcomes.
Example: A nurse closely monitors a patient's response to pain management
interventions, assessing pain levels, vital signs, and side effects of medications, and
adjusts the pain management plan based on the patient's feedback and clinical
observations.