Chapter 1

Introduction to Health
Assessment

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 Health
 Relative state in which a person is able to live to his or
her potential
 Includes the “7 Facets”
 Is not solely the absence of disease or eating right
 Client Health belief are different from one to another.
 Always ask about their perception of Health
 For example: what do you think it means to be
healthy?(open ended questions)

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The “7 Facets” of Health

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Health Assessment #1
 Definition: The processes used to evaluate the health
status of a person
 Asking pertinent questions to gather data
 Consists of:
o Comprehensive health history
o Complete physical examination
o Before performing either of the above introduce
yourself to the patient and sit at eye level if
possible.
o Provide privacy ,respect and nonjudgmental.

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Health History
 Past medical history
 Past physical issues
 Past psychological issues
 Social history
 Cultural history
 Spiritual beliefs
 Environmental influences
 Developmental level

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Physical Examination
 Structured head-to-toe examination
 Identify changes in patient’s body systems
 Unusual or abnormal findings may support history data or
trigger new questions
 Document all findings in a clear, concise manner
 Collate all information with medical records

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“The Nursing Process”
 The overall goals:
o Extrapolate the findings
o Prioritize the findings
o Formulate the plan of care
o Implement the plan of care

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Purpose of Health Assessment
 Determine a patient’s health status
 Determine the patient’s risk factors
 Determine the need for health education
 Develop a nursing plan of care

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Health Assessment #2
 Every person needs to have a complete assessment
 Ideally done on admission
 Circumstances may delay the completion; should be
completed once situation allows
o A critically ill patient coming into the ER—wait until
patient is stable to complete
o A patient with a professional relationship with the
nurse—just need updates
o A patient with dementia may require
supplementation from family

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Question #1
 Is the following statement True or False?
The nursing health assessment is not a requirement for
successfully caring for the patient.
A. True
B. False

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Answer to Question #1
 Is the following statement True or False?
 The nursing health assessment is not a requirement for
successfully caring for the patient.
 B. False
 The nursing health assessment is important for
developing the nursing care plan to ensure each patient
receives the care they need.

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Nursing vs. Medical Assessments
 Nursing  Medical
o Focus on diagnoses o Focus is on the
and treatment of diagnoses and
the actual or treatments of the
potential human disease
responses
o Identifies many
contributing factors to
the individual’s health
and wellness

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Health Care Team

 Nurse  Physical therapist

 Physician  Occupational therapist

 Nutritionist  Speech therapist

 Social worker  Dentist

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Health Assessment #3
 Nurse detects areas of concern requiring immediate
attention
 Nurse uses findings to decide the areas that take
precedence
 Health promotion and disease prevention are essential
areas of patient education

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Additional Components
 Individual’s personality and attitude
 Resilience
 Family dynamics
 Access to healthcare and resources
 Nutrition
 Exercise
 Culture
 Beliefs

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The Role of the Nurse #1

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Role of the Nurse #2
 Use findings and decide in which areas patient needs the
most care
 Deliver care across the lifespan
 Promote health and prevent disease
 Educate and counsel individuals, families, groups, and
communities
 Determine what affects the patient’s health
 Focus on health and goals of the patient

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Role of the Nurse #3
 Oversee the holistic care of each patient
 Collect data
 Make judgments that will impact patient safety and
quality of care
 Identify what is important on a daily basis for each
patient
 Carefully watch and listen to the patient to determine
what additional questions to ask
 Watch for subtle changes in the patient

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Role of the Nurse #4
 Rely on assessment skills
 Use the “7 Facets” to assess the patient
 Use information detected in assessment to work with the
patient to enhance quality of life
 Learn to detect a change in patient to enable providing
best care
 Take advantage of teaching opportunities that present
with the patient and family
 Continually reassess the patient for changes in order to
achieve the best results

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Question #3
 Which of the following is NOT one of the “7 Facets”?
A. Spiritual
B. Emotional
C. Cultural
D. Education

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Answer to Question #3
 Which of the following is NOT one of the “7 Facets”?
 D. Education
 The “7 Facets” consist of the patient’s physical,
emotional, social, cultural, developmental, and spiritual
aspects. The patient’s health status is the sum of these
facets and not solely the absence of disease or eating
right. The nursing health assessment should include
information in all seven of these categories.

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