LESSON I- Introduction to Health Assessment

Health assessment is the first phase of the nursing process and involves the collection and analysis of
client data. Although it is the first phase, it is an ongoing process. Data collected as part of the health
assessment process can be categorized as subjective and objective data.

Subjective data can include information about both symptoms and signs. Symptoms are something that
the client feels (e.g., nausea, pain, fatigue). The nurse will not know about a symptom unless the client
shares this information. Signs are observable, such as a rash, bruising, or skin perspiration. Signs can be
categorized as subjective or objective because the client may tell you about their rash, and you as the
nurse may also observe the rash. As reflected in Figure 1.1, a symptom is noted in the image on the left as
“I’m having pain” while a sign can be observed in the image on the right, which is the bruising on the left
arm.
Figure 1.1: Symptoms and signs

Shows a person saying I'm having pain and another person with a bruise on arm.

Why is health assessment important and what is the nurse's role in health assessment?
Health assessments are a key part of a nurse's role and responsibility. The assessment is a tool
to learn about your patient's concerns, symptoms and overall health.

What are the roles and responsibilities of the nurse?

Nurses are responsible for recognizing patients' symptoms, taking measures within their scope of
practice to administer medications, providing other measures for symptom alleviation, and
collaborating with other professionals to optimize patients' comfort and families' understanding and
adaptation.

What are 10 roles of a nurse?

Nurses care for injuries, administer medications, conduct frequent medical examinations, record
detailed medical histories, monitor heart rate and blood pressure, perform diagnostic tests,
operate medical equipment, draw blood, and admit/discharge patients according to physician
orders

What is the role of health assessment?

Health assessments are usually structured screening and assessment tools used in primary care
practices to help the health care team and patient develop a plan of care. Health assessment
information can also help the health care team understand the needs of its overall population of
patients.
 The components of a physical exam include:
 Inspection. Inspect each body system using vision, smell, and hearing to assess normal
conditions and deviations. Assess for color, size, location, movement, texture, symmetry, odors,
and sounds as you assess each body system.
 Palpation. Palpation requires you to touch the patient with different parts of your hands, using
varying degrees of pressure. Because your hands are your tools, keep your fingernails short and
your hands warm. Wear gloves when palpating mucous membranes or areas in contact with body
fluids. Palpate tender areas last.
 Percussion. Percussion involves tapping your fingers or hands quickly and sharply against parts
of the patient's body to help you locate organ borders, identify organ shape and position, and
determine if an organ is solid or filled with fluid or gas.
 Auscultation. Auscultation involves listening for various lung, heart, and bowel sounds with a
stethoscope.

What are the 4 principles of health assessment?

The four principles of Beauchamp and Childress - autonomy, non-maleficence, beneficence
and justice - have been extremely influential in the field of medical ethics, and are fundamental
for understanding the current approach to ethical assessment in health care.

PRIORITIES OF CARE

Why is clinical judgment important? How does it guide the provision of care?

Clinical judgment is important to ensure the nurse’s actions are based on the client’s most important needs.
Clients often have several needs, and some are more important than others. As such, nurses need to assess
and evaluate the priorities of care: what actions are most important to take first, and then what actions can
follow. Typically, priority actions are those that prevent clinical deterioration and death.

Because of the importance of recognizing clinical deterioration in a client, a nurse must always be attuned to
the set of physiological needs that are important to maintain life and prevent death. These priorities of care
are related to the ABCs – airway, breathing, and circulation – introduced above.

MASLOW’S HIERARCHY OF NEEDS

Priorities of care can be determined using several frameworks such as Maslow’s Hierarchy of Needs. For
example, at the most basic level, life requires an open airway to breathe, the physiological process of
breathing, and the circulation of blood and oxygen throughout the body. Airway, breathing, and circulation
are the ABCs, which you might have learned if you have taken a cardiopulmonary resuscitation (CPR)
course.

Maslow’s Hierarchy of Needs was developed to consider basic human needs and motivations of healthy
individuals (Bouzenita & Wood Boulanouar, 2016; Francis & Kritsonsis, 2006; Gambrel & Cianci, 2003).
Although not well known, Maslow’s work was closely influenced by the Blackfoot tribe in Canada (James
& Lunday, 2014). One version includes five levels of needs: those related to physiological, safety, love,
esteem, and self-actualization (Maslow, 1943), which can help prioritize care in nursing.

Figure 1.2 presents one adapted version of Maslow’s Hierarchy.

Figure 1.2: Maslow’s Hierarchy of Needs (see attribution statement at bottom of page)

Drawing upon this framework, a nurse can use health assessments to explore five levels of needs:

 Physiological needs – fundamental physical needs required for survival such as air, food/drink,
sleep, warmth/clothing/shelter.
o Are these basic physiological needs being met? Is the client’s breathing and circulation
supported?
 Safety – needs related to a secure physical and emotional environment.
o Does the client feel safe and secure in general in life? Does the client feel safe and secure in
the healthcare environment? Is the bed lowered to the lowest position when you finish your
assessment? Is the call bell in reach?
 Love and belongingness – needs related to relationships including friendship and family, intimacy
and affection, work, and trust and acceptance.
o Does the client feel love and belongingness in general in their relationships? More
specifically, does the client feel cared for by nurses and other healthcare providers?
 Esteem – feelings related to self-worth, dignity, respect, and achievement.
o Does the client feel respected and valued in general by others? Does the client feel respected
and valued within the healthcare environment?
 Self-actualization – a process or action of reaching one’s full potential and self-fulfillment.
o What is important to the client in terms of what they want to achieve in life in general? What
are the client’s goals that they may have for themselves in their own health and healing
journey? Does the client feel satisfied, confident, and accomplished?
Nursing Process
The nursing process is a fundamental staple concept to understand in nursing school, both for exams and
during clinicals with patients, and will follow you throughout your entire nursing career. ADPIE is an
acronym that stands for Assessment, Diagnosis, Planning, Implementation, and Evaluation. These are the
steps of the nursing process, which are chiefly the steps to providing proper care to your patient.
Most importantly, the nursing process (ADPIE) is one of the ultimate things you’ll be expected to learn and
master in nursing school, and for that matter, as a future nurse

The Nursing Process: ADPIE

ADPIE, or in other words, the nursing process, is a huge staple in the nursing care world. It is vital that you
have a strong foundation of it in order to be a successful future nurse, so that’s why we’re here to break it
down for you. The nursing process does involve a lot of critical thinking skills, and since many nursing test
questions are based on this concept, it’ll make your whole life easier once you understand it for good!
Now remember; the acronym ADPIE stands for:
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

ADPIE Add-Pie
Interestingly, the funny thing is that we actually use ADPIE in everyday situations without even realizing it.
Once you see how simple it is to think about, it will be easier to break it down during your exams, and with
managing patient care. Let’s take a non-nursing example here to show you what we mean.
Assessment

Imagine: you wake up on Monday morning after a late night of caring for patients during your clinical
rotation. You have a lot of studying to do for your nursing exam, and you know that you’re going to need
an extra big cup of coffee. Because it took a little longer to brew, and you’re running 10 minutes late to
class. You pour that delicious, warm drink into your thermos, frantically throw it in your backpack, and
book it to school. When you finally make it to class, you grab your computer out of your bag and open it
up, but it won’t turn on. What do you do first?

Well, first, you’re going to assess the situation (the “A” in ADPIE).

Why isn’t the computer turning on? Why is it all wet? And why is your thermos empty and everything
smells like coffee?

At this stage, you are playing detective and strictly gathering data. Similarly, in nursing, this would be the
stage when you first go in to see your patient, the beginning of the assessment, where we collect all the
data about the patient, both objective and subjective.

In this case, these would be things like your first impression and vitals. What does the patient look like?
Does the patient have pale skin? Is the patient groaning in pain? What do their vitals stable? Is their
breathing labored? Is the patient angry, scared, confused or delirious? When taking the health history, do
you notice a history of heart problems? What kind of medication is the patient taking?

These are all observations and data collection to determine the health of the patient when doing an
assessment on a patient. As the first step in the process, gathering all this information will allow you to
proceed with the next step: your nursing diagnosis.

Diagnosis

Now the “D” in ADPIE stands for diagnosis, and that brings us to our next step after gathering that data
that we were just presented with. Going back to our example: “Well,” you say to yourself, “it seems to me
from all my evidence here, that my coffee must’ve leaked out onto my computer, and therefore my
computer is not working because it has gotten soaked with coffee!” Good deduction, detective!

So just like that, in our clinical assessment if we are dealing with a patient, we make a nursing diagnosis,
where we identify actual or potential medical /health risks. The nursing diagnosis is developed by NANDA
and should be prioritized based on Maslow’s hierarchy of needs. This diagnosis is key to the next step in
the process: making a nursing care plan.

Planning

Now that brings us to “P” in the ADPIE acronym, which stands for planning.

Back to our computer example: When you look at your computer and have figured out the cause, you now
have to make a quick plan. What are you going to do to fix the problem? You decide here that you need to
run to get this computer fixed by a professional. “Let’s see,” you think, “I have to call to see if the store is
open, make an appointment, find out if youe computer was backed up, leave school, take the bus to 33rd
street, walk two blocks…”

When we apply that to nursing, and patient care, we make a plan based on the assessment and nursing
diagnosis of our patient. You would then set SMART goals, which is an acronym that stands for specific,
measurable, attainable, realistic and timely short-and long-term goals for the patient. From here, we can
move on to the implementation part of the process.

Implementation

Next comes the “I” in ADPIE; the implementation portion of the process. Let’s circle back to the computer
example.

Because implementation is the action part of your plan; where you actually get up and bolt to the
computer store to fix this, fast!

Notice here the difference between the planning stage and the implementation stage. In the planning
stage, you are simply forming the plan. No action has begun yet, The implementation stage, however, is
where you act on that specific plan. Or, intervening.

Similarly, when we take this back into nursing and patient care, this is where we implement our plan for
our patient. As the action portion of the process, this is where our plans are carried out. Implementation is
the step where we finally intervene to help them, like physically giving drugs, educate, monitor, etc. Now
we are moving forward with care. After this step, we must evaluate the outcome of such interventions.

Evaluation

And finally, we evaluate; the “E” in the ADPIE nursing process. Where does this bring us with the computer
example?
As the final step, you are done carrying out your plan, and here’s where you are waiting anxiously at the
computer store, and the person helping you comes out to tell you, “Well my friend, it’s your lucky day. It
was almost too late, but we saved your computer and it works like it’s brand new again. Now, remember,
keep liquids far away!”

Now with patient care, this would be where you ask yourself as a nurse, were we successful in making in
meeting the desired outcome? Did the plan work or is it in the process of being successful?

If goals were not met with the health of the patient, we need to reassess and begin the process over,
noting why the goals weren’t met, and make changes to the new plan of care for the patient to make sure
new goals will be completed, in order to accomplish the health goals of patient care.

LESSON II - Holistic Nursing Assessment

What is a
holistic needs assessment?
A holistic needs assessment is a discussion with your doctor, nurse, or other
health professional involved in your care to talk about your physical,
psychological, spiritual and social needs. The focus is on you as a whole – not
just your illness.

Who do I need a holistic needs assessment?

Any patient with a tumor of the brain or central nervous system will be offered
a holistic needs assessment. As part of your care, doctors, nurses and other
health professionals will need to gather information from you as part of your
medical treatment. During a holistic needs assessment, you can decide how
much information you would like to share about your current situation. It gives
you opportunity for you to talk about any worries or concerns you may have. It
will help to clarify your needs and ensure that you are referred to the relevant
services.
Many patients find having an assessment helpful as it can help to identify what
help is available. However, if you do not want to have an assessment, you do
not have to have one.

When will the holistic needs assessment take place?

A holistic needs assessment may be offered at certain times during your care,
including:

 Around the time of diagnosis or start of your treatment.

 The end of your treatment-when your surgery, radiotherapy or
chemotherapy has been completed.
 Any time that you ask for one.

It will most likely be carried out by the Clinical Nurse Specialist involved in
your care. You can contact your Clinical Nurse Specialist if you have any
issues you wish to discuss.

With your agreement the person carrying out your assessment will refer you to
other services that may be of help to you. Alternatively if you prefer, you will
be given written information about these services.

The Clinical Nurse Specialist can give you a written copy of what was
discussed during the assessment if this would be helpful for you.

How do I prepare for the holistic needs assessment?

Share the information in this leaflet with your partner and family (if you wish)
so that they can be of help and support. There may be information they need to
know, especially if they are taking care of you during any treatment you may
need. If you would like a member of the healthcare team to talk to your family
or friends, or provide them with written information, they are happy to do so.
Please ask.

Being told you have a tumor in the Brain or Central Nervous System (CNS) can
be very upsetting for you and those around you. You may have issues that are
important to you that you haven’t known who to talk to about. A holistic needs
assessment gives you the opportunity to meet with your doctor, nurse or other
health professional to discuss any concerns you may have relating to your
illness.

These issues might include:

 Symptoms and physical concerns. You may feel anxious about your
illness or about the changes in your body.
 Feelings and emotions. There is no “normal” reaction to being told you
have a brain or CNS tumour; everyone is different. It can be helpful to
discuss your reactions, especially if you are feeling very worried or
low.
  Difficulty with relationships. It may be that the relationships you have
with friends, your family or your partner have changed. Sexual
relationships can also be affected.
 Money worries. You may want to know more about the financial help
available to you.
 Other concerns. The assessment is there to help you. The person
completing the assessment will be happy to talk about whatever
issues are important to you.

How Are Holistic Health Assessments Different?

Most nurses have significant experience performing standard health assessments that are both
comprehensive and problem-focused. Through patient interviews and physical exams, both
standard and holistic assessments include a review of:

 Past personal medical history, including prior hospitalizations, illnesses and surgeries

 Family history such as general health, history of illness and cause of death

 Food, environmental and medication allergies, plus type and extent of reaction(s)

 Prescription and over-the-counter medication history, including dosages and routes of

administration

 Location and severity of pain

 Evaluation of fall risks

 Mental health, including signs of confusion, depression, substance abuse and suicidal
ideations

 Vital signs such as heart rate, blood pressure, temperature and oxygen saturation

However, in a holistic health assessment, a nurse typically dives deeper into a patient's health
history, spending more time and energy gathering information and identifying patterns or root
causes. Additionally, holistic assessments emphasize the following:

Person-centered care. Traditional assessments tend to be problem-focused, largely using the

information-gathering session to discuss the most acute medical issue, or "chief complaint."
Holistic assessments use a person-centered approach and include an extensive evaluation of the
patient's physiological, psychological, sociological, developmental, spiritual and cultural status.
The conversation covers these topics as well as lifestyle choices and habits such as exercise,
nutrition and sleep.
Mutual goal-setting. As part of a holistic health assessment, the nurse and patient work together
to establish wellness goals. Instead of prescribing a medication or treatment plan, the nurse
suggests tools and methods that may be helpful in achieving those goals, and the patient
determines the best strategies to adopt.
What Are the Benefits of Holistic Health Assessments?

Holistic nursing assessments seek to understand the unique challenges, strengths and goals of
each patient. Some benefits of this approach include:

Increased communication. By working together to establish goals and discussing options for the
best course forward, nurses and patients increase their communication and create more balanced,
collaborative interactions.
Patients feel valued. Many patients struggle with making long-term, healthful changes, especially
if they feel unheard or treated as just a number. Holistic assessments recognize all patients as
individuals by respecting their beliefs and values and encouraging them to actively craft goals and
care plans.
Improved outcomes. Helping patients gain more control over their healthcare decisions can
expedite their adoption of positive lifestyle changes and strengthen treatment plan adherence —
all of which may lead to improved outcomes.